Factors associated with intrauterine contraceptive device use among women of reproductive age group in Addis Ababa, Ethiopia: A case control study.

BACKGROUND: Intrauterine Contraceptive Device (IUCD) is a highly effective and reversible modern contraceptive, which is still significantly underutilized in Ethiopia. The aim of this study was to identify factors affecting the use of IUCDs among women of reproductive age group in Addis Ababa.
METHODS: Facility-based, unmatched case-control study was employed among randomly selected cases and controls in selected health centers in Addis Ababa from August to October 2017. The cases (n = 128) were women of reproductive age group who were IUCD users and controls (n = 256) were women of reproductive age group who were users of oral or injectable contraceptives during the study period. After randomly selecting two health center from each sub-city the number of cases and controls were equally allocated to each of the selected health centers. In each selected health center, all eligible cases were enrolled consecutively until the sample size was achieved. Two consecutive controls were selected for each case. Data was collected face-to-face by trained nurses by using structured questionnaire. Factors associated with IUCD use were identified by multi-variable binary logistic regression models using the backward conditional stepwise method.
RESULTS: In the multi-variable analysis, IUCD use was strongly associated with husbands/partners being supportive of IUCD use (Adjusted OR = 13.24, 95% CI; 5.30-33.02), being literate women (Adjusted OR = 5.31, 95% CI; 1.05-26.93), women having a perception of IUCD does not cause infection (Adjusted OR = 4.38, 95% CI; 1.45-13.26) and the source of information about IUCD being mass-media (Adjusted OR = 3.81, 95% CI; 1.49-9.74).
CONCLUSIONS: The findings of the study reinforce the need of husbands/partners involvement in the interventions to enhance utilization of IUCD. Moreover, due attention should also be provided for delivering IUCD-related messages in the public mass-media.

Introduction

Contraceptives reduce the number of abortions, prevent unintended pregnancies, and lower the incidence of death and disability related to complications of pregnancy and childbirth. It is reported that an additional 24 million abortions, 6 million miscarriages, 70,000 maternal deaths and 500,000 infant deaths would be prevented, if all women with an unmet need for contraceptives were able to use modern methods worldwide [1, 2]. However, only 33% of women in Africa used contraceptive methods in 2015 [2]. In Ethiopia contraceptive prevalence rate among married women has shown an increase from 28.6 percent in 2011 to 36 percent in 2016, resulting in a decline of total fertility rate from 4.8 in 2011 to 4.6in 2016 [3]. Nevertheless, Ethiopia still remains one of the countries with low contraceptive use rate, high fertility rate (the second populous and one of the highest fertility rates in Africa, with about 40% of its population is under fifteen) and high number of unintended pregnancies [4-8]. Moreover, the maternal mortality ratio is still high (412/100,000 women) [3]. Therefore, increasing the uptake of modern contraception is one of the solutions in order to decrease the fertility rate and to reduce the unmet need for family planning [4, 6, 9, 10].

The IUCD) is one of the most reliable and the most widely used reversible modern contraceptive method worldwide and has the potential to reduce the overall number of unintended pregnancies more than any other contraceptive method [11, 12]. Despite the fact that the copper-bearing IUCD brand TCu-380A is widely available in Ethiopia and is provided free of charge in government healthcare facilities, it is still very much underutilized [3]. Unlike other countries where IUCD is widely used such as: Scandinavian countries (18%), Asian nations (13%), the Near East and North Africa (12%) [13] and Kenya (4.8%) [13, 14], IUCD use in Ethiopia was only 2%, as reported by the Ethiopian Demographic and Health Survey of 2016 [3].

Even though, consistency and conclusiveness has not yet reached, studies in different parts of Ethiopia have shown several different factors affecting utilization of IUCDs. These factors include: age of the women, her religion, her level of education, a history of abortion, and perceived myths relating to the use [4–7, 9, 10, 15–21]. However, the problem of underuse of IUCD is still prevalent and much study is required to identify locally plausible determinants. Therefore, it is of a great importance to undergo a research in different areas of the city to maximize the scope of the study across a widely different socio-demographic and geographic area and to more precisely identify the current factors that are associated with low IUCD use.

Thus, understanding these factors may help for developing a strategy that can help in improving the utilization of IUCD in Addis Ababa and there by contribute towards decreasing the number of the unintended pregnancies and the fertility rate.

Materials and methods

Study setting and design

A facility-based unmatched case control study was conducted from August to October 2017 among women of reproductive age group (15–49 years old) who were seeking family planning services at the randomly selected health centers in Addis Ababa. Addis Ababa is the capital city of Ethiopia, with the population size of 3,384,569 million people out of which 52.6% were female, according to the 2007 census report [22]. The city is organized in ten administrative sub-cities. A health center in Ethiopia is the lowest level of an officially recognized healthcare facility that can insert IUCD. It is much closer to the community, serves about 25,000 people of the area and provides basic health care services such as: outpatient care, antenatal and delivery services, family planning services, HIV screening and care services, immunization, child health services, and some minor trauma care (e.g., burn dressing changes) [23]. All the health centers provide family planning services regularly, including the insertion and removal of IUCD.

Study population

The cases were women of reproductive age group (15–49 years old), permanent residents of Addis Ababa (i.e., were residents for ≥ 6 months), and were new users (first time users) of IUCD in the selected health centers during the study period. Whereas, the controls were women of reproductive age group (15–49 years old), permanent residents of Addis Ababa (i.e., were residents for ≥ 6 months), who were new users of hormonal contraceptives (oral, injectable or implants) in the selected health centers during the study period.

Sampling procedure

The sample size was determined using two population proportion formula by using age as a main determinant factor in IUCD utilization [4]; where 81.5% of IUCD users and 67.6% of non-IUCD users were reproductive women above the age of 25 and considering 95% CI, 80% power of the study, and a one case to two control ratio. The sample size calculated from the above assumptions gave 128 cases and 256 controls.

There were 98 health centers in Addis Ababa, out of which, 20 health centers (two from each sub-city) were selected by employing simple random sampling technique (lottery method). Then, the number of cases and controls were equally allocated to each of the selected health centers. In each health center, all the eligible reproductive age group women who were new IUCD-users were included in the study consecutively until the sample size was achieved.

For each case, two adjacent controls that used OCPs, implants or injectable contraceptives during the study period were selected and if the selected control did not fulfill the inclusion criteria, the next woman who used OCPs, implants or injectable contraceptives was considered.

Ethical considerations

Ethical clearance was obtained from Myungsung Medical College Institutional Review Board (IRB) and the letter of permission was obtained from Addis Ababa City Regional Health Bureau (S1 File). Subsequently, from each health center an official letter of permission was obtained. Thereafter, informed verbal consent was obtained from each study subject before participation in the interview. Since this study was solely based on interviewing the clients and no invasive procedures was used, informed verbal consent would suffice. The use of verbal consent was approved by the IRB. Moreover, informed verbal consent was more preferable than informed written consent by the study participants. This is because clients in Ethiopia, where the level of literacy is much lower, have a perception that putting a signature might have some legal consequences. Furthermore, signing a paper might hinder the clients from explaining their true feelings and might incline towards responding of only positive responses for the interview questions.

Documentation or recording of the informed verbal consent was possible by reading the information sheet for the clients and requesting for the consent of the participation (S1 Appendix). Whenever the client refuse to participate in the study, her questionnaire was closed and marked as “not consented” and the next family planning client was considered.

Data collection procedure

A face-to-face interview was conducted immediately after the method of choice of contraception is administered to a woman. Interview was administered by trained nurses and public health professionals by using structured questionnaire. The interviewers were not involved in the family planning service provision. The questionnaire was developed based on previously done similar studies obtained from literature review which were published under a CC-BY license [5, 7, 16, 17, 19]. The structured questionnaire (S1 Appendix) was first prepared in English language and translated into Amharic, the national language of Ethiopia.

Training was given to the data collectors on the purpose of the study, the contents of the questionnaire and on issues related to the confidentiality of the responses and the rights of respondents. A pre-test on 5% of sample size on a health center out of the selected heath centers was done and the questionnaire was corrected and modified based on the pre-test results. Supervision of the data collection procedures was made by the researchers on a daily basis. During these supervisory activities, quality and completeness of gathered information were checked and timely corrections were made to improve the quality, consistency and completeness of data of subsequent interviews.

Data management and analysis

Modern contraceptives in this study were defined as a product or medical procedure that interferes with reproduction from acts of sexual intercourse [24]. These includes: Sterilization (male and female), IUCDs, Subdermal implants, Oral contraceptives, Condoms (male and female), Injectables, Emergency contraceptive pills, Patches, Diaphragms and cervical caps, Spermicidal agents (gels, foams, creams, suppositories, etc.), Vaginal rings and Sponge. The natural methods of contraceptives were considered as non-modern contraceptives. These includes: Calendar rhythm methods, Withdrawal, Lactational amenorrhea, Abstinence [24].

IUCD users in this study were those women of reproductive age group who have got IUCD inserted for the first time only during the time of study. Whereas, non-IUCD users were those women of reproductive age group who only used hormonal contraceptives (e.g., OCPs, implants or injectable) during the time of study. A woman was considered knowledgeable of the IUCD based on whether she has mentioned IUCD when asked to enumerate the family planning methods she knew during the study. If the woman had mentioned IUCD as one of the family planning methods, she was considered as having knowledge of IUCD as method of contraception.

Data was entered, cleaned and analyzed using SPSS (Statistical Package for Social Sciences) version 20 software. Data were checked for inconsistencies and missing values; then variables were defined, categorized and recoded for analysis. Descriptive summary was explained by frequency and percentage. Factors associated with IUCD use were identified first by bivariate analysis and then multi-variable binary logistic regression analysis using backward conditional stepwise method. Those variables with p-value <0.25 in the bivariate analysis were included in the multi-variable analysis. Odds ratios (OR), 95% confidence interval (CI) and p-value set less than 0.05 were used to determine the statistical significance of the associations between independent variables and the dependent variable. Multi-collinearity between variables was assessed using the multi-collinearity diagnostics (Variance Inflation Factor and tolerance test). The final multi-variable binary logistic regression model was found to be fit based on the finding of the Hosmer-Lemeshow goodness-of-fit test.

Results

Socio-demographic characteristics

A total of 128 cases and 256 controls were interviewed and their data were analyzed. Four (3.1%) of the cases and 43 (16.8%) of the controls were younger than 20 years. Majority of the cases (93.8%) and controls (75.2%) were married. More than three-fourths of the cases (79.6%) and controls (84.4%) were Christian. Only 7 (5.5%) of cases and 34 (13.2%) of controls were illiterate (not able to read and write). About half (46.9%) of cases and 118 (45.7%) of controls were house wives. In the bivariate analysis, IUCD use was associated with age, marital status and educational status of the women (Table 1).

Table 1

Socio-demographic characteristics of women and its association with IUCD use in Addis Ababa, 2017.

Variables	Case (n = 128)	Control (n = 256)	p-value
Age
15–20	43 (89.6%)	4 (10.4%)
21–30	159 (72.3%)	61 (27.7%)	0.001
31–40	44 (44.0%)	56 (56.0%)
41–49	10 (58.8%)	7 (41.2%)
Marital status
Not Married or divorced/widowed	8 (11.1%)	64 (88.9%)
Married	120 (38.5%)	192 (61.5%)	0.0001
Religion
Muslim	102 (72.9%)	38 (27.1%)
Christian	26 (10.7%)	218 (89.3%)	0.18
Educational status
Illiterate	7 (17.1%)	34 (82.9%)
Literate	121 (35.3%)	222 (64.7%)	0.024

Characteristics of reproductive history

The majority of cases (94%) and controls (69.4%) had a history of pregnancy and the majority (69.3%) of the pregnancies was planned. About forty percent of cases and thirty percent of controls had three or more births. In a majority of cases (70.8%) and controls (43%), age of their youngest child was 2 years or higher. More than 20% of the cases and controls had history of abortion and more than half of the cases and more than three-fourths of the controls had future plan of giving birth.

Reproductive characteristics of respondents that were associated with IUCD use in the bivariate analysis include; ever being pregnant, age of youngest child, and future plan of fertility (Table 2).

Table 2

Characteristics of reproductive history and its association with IUCD use among reproductive age women in Addis Ababa, 2017.

Variables	Case (n = 128)	Control (n = 256)	P-value
Ever pregnant
No	8 (9.2%)	79 (90.8%)
Yes	120 (40.4%)	177 (59.6%)	0.0001
Number of live birth (parity)
≤2 births/children	75 (27.3%)	200 (72.7%)
>2 births/children	53 (48.6%)	56 (51.4%)	0.0001
History of abortion
Yes	27 (30.7%)	61 (69.3%)	0.55
No	101 (34.1%)	195 (65.9%)
Age of the youngest child (n = 297)
≤2 years	35 (25.9%)	100 (74.1%)	0.04
>2 year	85 (52.5%)	77 (47.5%)
Future plan of fertility
To space birth	66 (24.2%)	207 (75.8%)
To stop birth	62 (55.9%)	49 (44.1%)	0.0001

Contraceptive knowledge and attitude

All of the study participants heard about at least one of the modern family planning methods and majority of the cases (45.3%) and controls (32.6%) knew four or more modern contraceptive methods. As indicated in Table 3 below, about 39% of cases and 80% of controls reported that they received information about family planning from healthcare providers. Almost all of the cases (98%) and less than half of the controls (42.6%) were knowledgeable about IUCD. A substantial proportion of the cases stated reasons for their IUCD use was because it was chosen by the service provider (33.6%) and husband/partner approval (23.4%).

Table 3

Knowledge and attitude towards IUCD use and its association among reproductive age women in Addis Ababa, 2017.

Variables	Case (n = 128)	Control (n = 256)	P-value
Number of modern contraceptive methods mentioned by the women
One	5 (13.9%)	31 (86.1%)
Two	36 (35.3%)	66 (64.7%)	0.004
Three	29 (27.6%)	76 (72.4%)
Four and more	58 (41.1%)	83 (58.9%)
Source of information about the contraceptive methods
Health facility (healthcare provider)	50 (19.7%)	204 (80.3%)
Media or friends	78 (60.0%)	52 (40.0%)	0.0001
Husband’s/partner’s opinion towards IUCD
Against	29 (12.3%)	207 (87.7%)
Supporting	99 (66.9%)	49 (33.1%)	0.0001
Comfortable of exposure during IUCD insertion
No	58 (24.1%)	183 (75.9%)
Yes	70 (48.9%)	73 (51.1%)	0.0001

Concerning myths and misconceptions towards the use of IUCD; 8.6% of the cases and 10.1% of controls perceive that IUCD causes infertility, 11.7% of the cases and 31.4% of the controls perceive that IUCD causes infection in the uterus, 4.7% of the cases and 31.4% of the controls perceive that IUCD causes cancer, 5.5% of the cases and 15.9% of the controls perceive that IUCD affects sexual intercourse, and 10.9% of the cases and 20.9% of the controls perceive that IUCD migrates to other body organs.

Those women who were currently using OCPs, implants or injectable (controls) were requested to indicate the reasons for not using IUCD. More than a quarter (29.4%) of the non-IUCD user’s reason for not using IUCD was fear that IUCD causes pain in pelvic region after insertion. Moreover, irregular bleeding during menstruation, risk of uterine perforation, risk of cancer, not suitable with laborious work, wanted short-term methods only, husband’s disapproval and increased risk of PID (infection) were also reported as reasons given by controls for not using IUCD.

In the bivariate analysis, IUCD use was associated with knowing four or more modern contraceptive methods, information sources being media or friends, being comfortable of exposing private organs during insertion, supporting opinion of husband/partner, perceiving that IUCD causes infection, perceiving that IUCD affects sexual intercourse and perceiving that IUCD may migrate to other organs (Table 4).

Table 4

Perception towards IUCD use and its association among reproductive age women in Addis Ababa, 2017.

Variables	Case	Control	P-value
Perceives that IUCD causes infertility
Yes	11 (29.7%)	26 (70.3%)
No	117 (33.7%)	230 (66.3%)	0.63
Perceives that IUCD causes infection
Yes	15 (16.0%)	79 (84.0%)
No	113 (49.1%)	177 (50.9%)	0.0001
Perceives that IUCD causes cancer
Yes	6 (25.0%)	18 (75.0%)
No	122 (33.9%)	238 (66.1%)	0.37
Perceives that IUCD affects sexual intercourse
Yes	7 (14.9%)	40 (85.1%)
No	121 (35.9%)	216 (64.1%)	0.006
Perceives that IUCD may results in pregnancy
Yes	16 (59.6%)	38 (40.4%)	0.53
No	112 (33.9%)	218 (66.1%)
Perceives that IUCD may migrate to other organ
Yes	14 (21.2%)	52 (78.8%)	0.02
No	114 (35.8%)	204 (64.2%)

Determinants of IUCD use

After controlling for confounding variables in the multi-variable binary logistic regression analysis using backward stepwise method (Table 5), IUCD use was associated with husbands/partners being supportive, educational status, women having a perception of IUCD does not cause infection and the source of information about IUCD being mass media/friends.

Table 5

Multi-variable analysis showing factors associated with IUCD use among reproductive age women in Addis Ababa, Ethiopia in 2017.

Variables	Cases	Control	Crude OR (95% CI)	Adjusted OR (95% CI)	P-value
Religion
Muslim	102 (72.9%)	38 (27.1%)	1.00	1.00
Christian	26 (10.7%)	218 (89.3%)	0.68 (0.39–1.18)	0.35 (0.10–1.25)	0.11
Educational status
Illiterate	7 (17.1%)	34 (82.9%)	1.00	1.00
Literate	121 (35.3%)	222 (64.7%)	2.65 (1.14–6.15)	5.31 (1.05–26.93)	0.044
Age of the youngest child
≤2 years	35 (25.9%)	100 (74.1%)	1.00	1.00	0.066
>2 year	85 (52.5%)	77 (47.5%)	3.15 (0.93–5.17)	3.24 (0.74–7.48)
Source of information
Healthcare provider	50 (19.7%)	204 (80.3%)	1.00	1.00
Media or friends	78 (60.0%)	52 (40.0%)	6.12 (3.83–9.77)	3.81 (1.49–9.74)	0.005
Husband/partner’s opinion			1.00
Against	29 (12.3%)	207 (87.7%)	14.42 (8.59 − 24.21)	13.24 (5.30 − 33.02)	0.0001
Supporting	99 (66.9%)	49 (33.1%)
IUCD causes infection
Yes	15 (16.0%)	79 (84.0%)	1.00	1.00	0.0001
No	113 (49.1%)	177 (50.9%)	4.89 (2.63–9.10)	4.38 (1.45–13.26)
IUCD may migrate
Yes	14 (21.2%)	52 (78.8%)	1.00	1.00	0.085
No	114 (35.8%)	204 (64.2%)	3.42 (1.78–6.57)	3.69 (0.83–16.39)

Women whose husbands/partners were supportive of IUCD use were about thirteen times more likely to use IUCD than those women whose husbands/partners were against IUCD use (Adjusted OR = 13.24, 95% CI; 5.30–33.02). The odds of IUCD use among the literate women were five times higher than the illiterate women (Adjusted OR = 5.31, 95% CI; 1.05–26.93). Likewise, women who had a perception that IUCD does not cause infection were four times more likely to use IUCD than their counterparts (Adjusted OR = 4.38, 95% CI; 1.45–13.26). Similarly, the odds of IUCD use among women who received information about IUCD from mass media or friends were about four times higher as compared to those who received information from healthcare providers (Adjusted OR = 3.81, 95% CI; 1.49–9.74).

Discussion

The study assessed the factors affecting the use of IUCD in Addis Ababa, in order to identify factors that may be inhibiting utilization of IUCD and to present recommendations passed on. After controlling for confounding variables; IUCD use was associated with husbands/partners being supportive, literate status, women having a perception of IUCD does not cause infection, and the source of information about IUCD being mass media/friends. However, religion and having a perception that IUCD will migrate to other organs of the body were not significantly associated.

It is interesting to note that husband’s/partner’s support is a strong determining factor for IUCD use in Addis Ababa. Women whose husband/partner is supportive of IUCD use were about thirteen times more likely to use IUCD than those women whose husband/partner is against IUCD use. This finding of the study is consistent with the findings from other parts of Ethiopia [16, 17, 19], Nepal [25] and Malawi [26]. Husband’s/partner’s support should be targeted to increase utilization of IUCDs. Particularly, in developing countries like Ethiopia, where decision making ability of the women is lower and the tradition of the country is suppressive of the women, it is very much crucial to involve husbands/partners in the information, education and communication programs to enhance utilization of IUCD [21, 27].

This study revealed that literate status was found to be significantly associated with IUCD use. This finding of the current study is consistent with those studies conducted in Ethiopia and other parts of Africa [17, 19, 20, 26, 28]. For instance, according to the finding of Ethiopian Health and Demographic Survey of 2016, the IUCD use was 0.5 percent for women with no education compared with 7 percent of women with more than secondary education [3]. This can be explained by those women with higher educational level are more likely to hold positive attitude towards IUCD use, have a greater knowledge about family planning options and have more autonomy within families about the decision to use contraceptive methods than women with no education [25].

Long standing beliefs, myths and misconception were cited in different studies as the major factors responsible for the underuse of IUCD [25, 28]. In a similar manner, this study also revealed that perception of the women that IUCD cause infection was found to be prohibiting factor for IUCD use. Moreover, majority of the controls had perception that IUCD can cause infertility, can cause cancer, affect sexual intercourse and migrate to other organs. This finding of the current study implies that there is still lack of awareness towards IUCD among the reproductive age women in Addis Ababa.

Although all the participants of the present study heard about at least one modern family planning methods, the source of information was one of the determinants for their use of IUCD. Women who heard about IUCD from mass-media and/or friends were more likely to use IUCD than those women who heard from healthcare providers. This finding of the study calls for provision of due emphasis on the mass-media utilization to deliver important health messages related to IUCD [9, 17, 25, 29]. Mass media outlets are accepted as a reliable sources of information than other sources because of many reasons such as; mass media messages are broadcasted for millions of audiences at once, messages can be nationally monitored, the approaches to deliver mass-media messages are often explicit and in a demonstrable fashion and the mass media messages can impact other important members of the family, in this instance, husbands, whom this study demonstrates are important in choosing or refusing IUCD use [30, 31]. On the other hand, messages that are communicated by the healthcare providers working in the health centers might not be considered as reliable as mass media messages. This is because health centers are among the lowest units of health care delivery units in Ethiopia, where health officers or clinical nurses are providing services [3, 23]. This finding has implications that the quality and contents of the messages delivered by the healthcare providers in the health centers might not address the information demand of the community. Therefore, the finding calls for addressing the gap through proper training on the preparation and delivery of health messages [26].

This study was conducted in multiple study areas of the city which maximized the scope of the study and helped to identify the current factors that are associated with IUCD use. However, in this study, private facilities and hospitals were not included; this might limit the generalization of the study. However, more affluent and better educated women have the means (e.g., money, knowledge, educational status, transportation) to attend private clinics and, based upon this study, are more likely to use IUCDs than the general population. Moreover, this study is solely in the urban setting and cannot be generalized for the rural women. Understanding socio-cultural determinants of IUCD use was not possible in this study, as the study was purely quantitative. Further qualitative or mixed approach studies exploring the socio-cultural determinants of IUCD use in urban and rural population of Ethiopia should be conducted. This study might be also limited by social-desirability bias with regard to reporting the myths and miss-conceptions towards IUCD and the literacy level of the participants. Absence of matched controls (e.g., in terms of age) might have also affected the finding of the study. Furthermore, multi-disciplinary studies including the social sciences perspective would be helpful to determine the role of husband’s involvement in decision making process of contraceptive use.

Conclusions

For the fertility rates continue to decline, unintended pregnancies, unsafe abortions and associated mortalities to be reduced the use of contraceptives plays an important role. However, IUCD use is determined by husbands/partners being supportive, literate status, women having a perception of IUCD does not cause infection, the source of information about IUCD being mass media/friends and women with age of youngest child >2 years. Husband’s/partner’s support is of critical importance because of its strong association with IUCD use. Therefore, all the interventions to enhance utilization of IUCD should involve husband’s/partner’s. Moreover, due attention should also be provided for delivering IUCD related messages in the public mass-media.

Research Ethics Committee approval letter.

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Questionnaire.

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Dataset used in the study.

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Checklist of items that should be included in reports of observational studies.

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1 Nov 2019

PONE-D-19-22523

Factors Associated with Intrauterine Contraceptive Device Use among Women of Reproductive Age Group in Addis Ababa, Ethiopia: A Case Control Study

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Additional Editor Comments:

In addition to points raised by the reviewers, I would suggest that the authors re-structure the Discussion to discuss topics in order based on strength of association. Partner support was the strongest determinant of selecting an IUCD but is only discussed midway through this section. The limitations section also do not encompass the full range of limitations, included reported nature of many of the co-variates, the non-representative sample selection and use of non-matched controls that further limit generalizability; please make this section more robust. The manuscript would benefit from review by a native English speaker for editing and flow and the Methods section can be made more concise.

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

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: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: No

**********

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

**********

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: Yes

Reviewer #2: No

**********

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: An observation study of 128 cases and 256 controls were selected at a 1:2 ratio to identify factors affecting the use of Intrauterine Contraceptive Devices (IUCDs) among women of reproductive age group in Ethiopia. Logistic regression analysis revealed that literate status, source of information about IUCD being mass media/friends, supportive partners, and women having a perception of IUCD does not cause infection were independent predictive factors of IUCD use when controlling for confounders.

Minor revisions:

1- Abstract: No need to state the sample sizes twice in the abstract.

2- Modify the results and/or conclusion to indicate that the significant factors in the multivariate logistic model were INDEPENDENT predictors of IUCD use.

3- Line 121: Provide additional details for justifying the study’s target sample size. The power calculation should include: sample size, alpha level (indicating one or two-sided), minimal detectable difference and statistical testing method.

4- Lines 173 and 185: The standard terminology for bivariate is univariate logistic regression.

5- Tables: Define all abbreviations and provide only the overall p-values rather than pairwise p-values for variables with more than two categories.

6- Tables: Include percentages corresponding to the frequencies.

7- When discussing the results of the multivariate model, clarify that four factors were significant when adjusted for the nonsignificant factors that were also included in the model. This has been stated properly in the discussion, but should also be included in the results section of the abstract.

Reviewer #2: Reviewer: Mengistu Meskele

Date: 05 October 2019

Title: Factors Associated with Intrauterine Contraceptive Device Use among Women of Reproductive Age Group in Addis Ababa, Ethiopia: A Case Control Study

Manuscript number: PONE-D-19-22523

General comments

Generally, this research title currently a public health important in Ethiopia. Though, it needs further improvement in order to adhere the publication criteria of the journal. My comments are presented below

The study presents the results of original research= Yes

2. Results reported have not been published elsewhere=Yes

3. Experiments, statistics, and other analyses are performed to a high technical standard and are described in sufficient detail. No

4. Conclusions are presented in an appropriate fashion and are supported by the data. No

5. The article is presented in an intelligible fashion and is written in Standard English. No, some improvement is needed.

6. The research meets all applicable standards for the ethics of experimentation and research integrity. Not separately explained in the method section, not ethics approval letter attached

7. The article adheres to appropriate reporting guidelines and community standards for data availability =Yes

Specific comments

� Title and sub-titles should be sentence case and follow journal style of formatting manuscript

� The formatting styles of tables in this manuscript are not suitable for publication. Each variable should be written in cell or should follow the journal style. Also one table should not be presented two to three pages. If possible, it would be each could be table to present in one page?

� Table 4. COR and AOR should be presented along with 95% CI in one cell?

� In table 1,2 and 3 the COR and 95% CI columns should be removed?

� Abstract: should not be more than 300 words?

� Why the definition of cases was only selected from new users of family planning? On other hand your controls were selected both from new and return clients? Definition and selection criteria for cases and controls should be the same. What is your justification for this difference?

From line 123, From all the health centers in Addis Ababa, 20 health centers (two from each sub-city) were selected by employing simple random sampling technique?

� Question: How many health centers were there in AA? Why only 20 were selected?

� Unnecessary capitalization and inconsistency in use of abbreviations are identified. For instance, intrauterine Device/IUCD. Sometimes you use IUCD but other time intrauterine Device. If once you abbreviated it in the first time use, use IUCD throughout?

� Did you check the model fitness test? That means post estimation test? How did you controlled over matching? What about multicolloniarity?

� Letter for Ethical clearance file should be attached as supporting information?

� List of abbreviations should be removed from line numbers 324-331?

� Discussion: You didn’t consider negative finding in your discussion. You discussed only positive finding. If possible consider it.

� Strengths and limitations should be stated at end of discussions?

� Presentation of 95% CI: You put it not consistently in your document throughout, sometimes you used one digit, and other times 2 digits. Be consistent and I recommend 2 digits. It is usually preferable and be consistent?

� Line 236: You used p-value <0.20 in the bivariate analysis. Why p- value < 0.2? Why not 0.25?. If you could have used backward conditional stepwise regression rather than enter method, your multivariable analysis will be very sound, also your table also cannot three to four pages. Consider this?

� References are not completed and an acceptable label.

� References 2, 3,8,9,10,11,16,17,18,22,23,28,29,30,31, are either not completed or URL and accessed dates are missed, also the authors naming are not correct. List of more than 6 authors, you should write the first 6 authors and use et al.?

� Financial disclosure, conflict of interest and source of funding are not mentioned.

Conclusion

� In the conclusion section, the statement “For the fertility rates continue to decline, unintended pregnancies, unsafe abortions and 317 associated mortalities to be reduced the use of contraceptives plays an important role”. This sentence can be removed and the author can bring conclusions from his/her finding rather than stating the above unrelated issues of the study.

**********

6. 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: Yes: Mengistu Meskele

[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 to be viewed.]

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 us at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: Reviwers Comment MM PONE-D-19-22523.docx

Click here for additional data file.

26 Nov 2019

Point by point response

PONE-D-19-22523

Factors Associated with Intrauterine Contraceptive Device Use among Women of Reproductive Age Group in Addis Ababa, Ethiopia: A Case Control Study

Dear editor and reviewers,

Thank you for your comments and suggested revisions that have helped us to improve the manuscript. We have revised our manuscript according to your constructive and very insightful comments and suggestions. Attached you will find our revised manuscript and below you will find a response to each of your comments.

Response for editor’s comment

In addition to points raised by the reviewers, I would suggest that the authors re-structure the Discussion to discuss topics in order based on strength of association. Partner support was the strongest determinant of selecting an IUCD but is only discussed midway through this section. The limitations section also do not encompass the full range of limitations, included reported nature of many of the co-variates, the non-representative sample selection and use of non-matched controls that further limit generalizability; please make this section more robust. The manuscript would benefit from review by a native English speaker for editing and flow and the Methods section can be made more concise.

Response: Thank you for the suggestion. The discussion is re-structured now to discuss the strongest predictor first. Also, limitations of the study is now detailed. The revised manuscript is also reviewed by native English speaker.

Response for reviewer 2 comments and suggestions

R2: Title and sub-titles should be sentence case and follow journal style of formatting manuscript

Response: Thank you, now it is corrected.

R2: The formatting styles of tables in this manuscript are not suitable for publication. Each variable should be written in cell or should follow the journal style. Also one table should not be presented two to three pages. If possible, it would be each could be table to present in one page?

Response: Thank you for the comment. The formatting of the tables are now corrected.

R2: Table 4. COR and AOR should be presented along with 95% CI in one cell?

Response: Thank you, COR and AOR are now presented along with 95% CI in one cell.

R2: In table 1,2 and 3 the COR and 95% CI columns should be removed?

Response: Thank you for the suggestion. COR and 95% CI are removed from the tables.

R2: Abstract: should not be more than 300 words?

Response: Thank you, it is corrected.

R2: Why the definition of cases was only selected from new users of family planning? On other hand your controls were selected both from new and return clients? Definition and selection criteria for cases and controls should be the same. What is your justification for this difference?

From line 123, From all the health centers in Addis Ababa, 20 health centers (two from each sub-city) were selected by employing simple random sampling technique?

Response: Thank you for the comment. Actually, we have included only new cases and controls to reduce the potential biases. Now, this is corrected throughout the revised manuscript.

Twenty health centers out of the total 98 health centers were selected by simple random sampling technique (lottery method).

R2: Question: How many health centers were there in AA? Why only 20 were selected?

Response: There were 98 health centers in Addis Ababa. To increase the scope and ensure representativeness of the population attending care, we randomly selected 20 health centers (two from each sub-city). It was not feasible to take more than 20 health centers. We employed simple random sampling technique to ensure equal chance of being included in the study.

R2: Unnecessary capitalization and inconsistency in use of abbreviations are identified. For instance, intrauterine Device/IUCD. Sometimes you use IUCD but other time intrauterine Device. If once you abbreviated it in the first time use, use IUCD throughout?

Response: Thank you. IUCD is used throughout the manuscript.

R2: Did you check the model fitness test? That means post estimation test? How did you controlled over matching? What about multicolloniarity?

Response: Yes, we have checked model fitness test by Hosmer-Lemeshow goodness-of-fit test. Also, we have checked multicoliniarity by using the multicoliniarity diagnostics (VIF and Tolerance test).

R2: Letter for Ethical clearance file should be attached as supporting information?

Response: Attached as supporting information

R2: List of abbreviations should be removed from line numbers 324-331?

Response: Thank you, addressed.

R2: Discussion: You didn’t consider negative finding in your discussion. You discussed only positive finding. If possible consider it.

Response: Thank you. We have now considered discussing pertinent negative findings in the discussion.

R2: Strengths and limitations should be stated at end of discussions?

Response: We have detailed the strengths and limitations of the study

R2: Presentation of 95% CI: You put it not consistently in your document throughout, sometimes you used one digit, and other times 2 digits. Be consistent and I recommend 2 digits. It is usually preferable and be consistent?

Response: Thank you for the comment. We have now put the numbers consistently

R2: Line 236: You used p-value <0.20 in the bivariate analysis. Why p- value < 0.2? Why not 0.25?. If you could have used backward conditional stepwise regression rather than enter method, your multivariable analysis will be very sound, also your table also cannot three to four pages. Consider this?

Response: Thank you for the comment. We used P value <0.25 as a criteria to enter variables into the multi-variable model. Also, we have now re-analyzed our data using the backward conditional stepwise binary logistic regression model and the findings are reported.

R2: References are not completed and an acceptable label.

� References 2, 3,8,9,10,11,16,17,18,22,23,28,29,30,31, are either not completed or URL and accessed dates are missed, also the authors naming are not correct. List of more than 6 authors, you should write the first 6 authors and use et al.?

Response: Thank you, the formatting of the references is now corrected.

R2: Financial disclosure, conflict of interest and source of funding are not mentioned.

Response: Based on the PLOS ONE submission guidelines, statements on financial disclosure and conflict of interest were given in the submission form in the system.

R2: In the conclusion section, the statement “For the fertility rates continue to decline, unintended pregnancies, unsafe abortions and 317 associated mortalities to be reduced the use of contraceptives plays an important role”. This sentence can be removed and the author can bring conclusions from his/her finding rather than stating the above unrelated issues of the study.

Response: The introductory sentence of the conclusion is used to link our findings with its public health importance. Then, we have concluded the study based on the findings of the study.

Submitted filename: Response to reviewers.docx

Click here for additional data file.

7 Jan 2020

PONE-D-19-22523R1

Factors associated with intrauterine contraceptive device use among women of reproductive age group in Addis Ababa, Ethiopia: A case control study

PLOS ONE

Dear Mr. Dereje,

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.

We would appreciate receiving your revised manuscript by Feb 21 2020 11:59PM. When you are 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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To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

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). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.

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An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Catherine S. Todd

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

The authors have been largely responsive to previous comments but both reviewers and I note that the authors disregarded responding to several comments in the first review. There was no response to Reviewer 1's critiques; Reviewer 2 noted several comments that did not receive a response, and I note that the Limitations section still does not include some major limitations that were brought to the authors' attention in the first review, namely the reported nature of several of the covariates (e.g., literacy) and the absence of matched controls. Further, though you state the revised manuscript was reviewed by a native English speaker, there remain multiple places where verb tense, punctuation, and other grammatical errors are present or examples of awkward phrasing (which can be adjusted and reduce word count in the abstract). For example: "In each health center, all the eligible cases were included in the study consecutively until the desired sample size was achieved. For each case, two adjacent controls were selected to be included in the study." can be improved to "In each selected health center, all eligible cases were enrolled consecutively until sample size was achieved. Two consecutive controls were selected for each case." Last, there appear to be different fonts within the manuscript and portions do not comply with formatting requirements. Please attend to all of these matters completely and in the response letter, please state what was done in response and provide illustrative text rather than stating the query was addressed, as this was not consistently the case with the last revision. Thus, you are invited to revise and re-submit.

[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: (No Response)

Reviewer #2: All comments have been addressed

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

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: Minor revisions:

1- Abstract: No need to state the sample sizes twice in the abstract.

2- Modify the results and/or conclusion to indicate that the significant factors in the multivariate logistic model were INDEPENDENT predictors of IUCD use.

3- Line 121: Provide additional details for justifying the study’s target sample size. The power calculation should include: sample size, alpha level (indicating one or two-sided), minimal detectable difference and statistical testing method.

4- Lines 173 and 185: The standard terminology for bivariate is univariate logistic regression.

5- Tables: Define all abbreviations and provide only the overall p-values rather than pairwise p-values for variables with more than two categories.

6- Tables: Include percentages corresponding to the frequencies.

7- When discussing the results of the multivariate model, clarify that four factors were significant when adjusted for the nonsignificant factors that were also included in the model. This has been stated properly in the discussion, but should also be included in the results section of the abstract.

Reviewer #2: Minor comments

1. Contribution: Equal or unequal contribution should be explained at first page?

2. Style: Font style for title and headings should be adhered journal style?

3. Table 5. Cross tabulation for cases and controls should be included?

**********

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: Yes: Mengistu Meskele

[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 to be viewed.]

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 us at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: Reviewer MM comment 17 December 2019.docx

Click here for additional data file.

13 Jan 2020

Point by point response

PONE-D-19-22523

Factors Associated with Intrauterine Contraceptive Device Use among Women of Reproductive Age Group in Addis Ababa, Ethiopia: A Case Control Study

Dear editor and reviewers,

Thank you for your comments and suggested revisions that have helped us to improve the manuscript. We have revised our manuscript according to your constructive and very insightful comments and suggestions. Attached you will find our revised manuscript and below you will find a response to each of your comments.

Response for editor’s comment

Editor: The authors have been largely responsive to previous comments but both reviewers and I note that the authors disregarded responding to several comments in the first review. There was no response to Reviewer 1's critiques; Reviewer 2 noted several comments that did not receive a response, and I note that the Limitations section still does not include some major limitations that were brought to the authors' attention in the first review, namely the reported nature of several of the covariates (e.g., literacy) and the absence of matched controls. Further, though you state the revised manuscript was reviewed by a native English speaker, there remain multiple places where verb tense, punctuation, and other grammatical errors are present or examples of awkward phrasing (which can be adjusted and reduce word count in the abstract). For example: "In each health center, all the eligible cases were included in the study consecutively until the desired sample size was achieved. For each case, two adjacent controls were selected to be included in the study." can be improved to "In each selected health center, all eligible cases were enrolled consecutively until sample size was achieved. Two consecutive controls were selected for each case." Last, there appear to be different fonts within the manuscript and portions do not comply with formatting requirements. Please attend to all of these matters completely and in the response letter, please state what was done in response and provide illustrative text rather than stating the query was addressed, as this was not consistently the case with the last revision. Thus, you are invited to revise and re-submit.

Response: Thank you for the comments. The prior request sent to us was to review comments/suggestions based on the comments from the editor and reviewer 2. That is why we didn’t reply for the reviewer 1 questions. Now, we have replied to the reviewer 1 queries too.

The limitations of the study is also further detailed to address the reported nature of the covariates and the absence of matched controls. The study might be also limited by social-desirability bias with regard to reporting the myths and miss-conceptions towards IUCD and the literacy level of the participants. Absence of matched controls (e.g., in terms of age) might have also affected the findings of this study.

Consistency of font styles and formats are addressed now. To further improve the overall flow of the manuscript, it is reviewed by a native English speaker.

Response for Reviewer 1 comments

R1: 1- Abstract: No need to state the sample sizes twice in the abstract.

Response: Thank you, it is addressed. Sample size is mentioned once in the revised manuscript.

R1: Modify the results and/or conclusion to indicate that the significant factors in the multivariate logistic model were INDEPENDENT predictors of IUCD use.

Response: Thank you, this is indicated now in the revised manuscript. The adjusted odds ratio also indicates that the predictors are independently associated with the IUCD use after the confounding factors are controlled.

R1: Line 121: Provide additional details for justifying the study’s target sample size. The power calculation should include: sample size, alpha level (indicating one or two-sided), minimal detectable difference and statistical testing method.

Response: Thank you for the comment. It is addressed and all the entities for sample size calculations were given.

R1: Tables: Define all abbreviations and provide only the overall p-values rather than pairwise p-values for variables with more than two categories.

Response: Thank you for the suggestion. All abbreviations defined. The overall p-values were given in the tables.

R1: Tables: Include percentages corresponding to the frequencies.

Response: Thank you, percentages are now included.

R1: When discussing the results of the multivariate model, clarify that four factors were significant when adjusted for the nonsignificant factors that were also included in the model. This has been stated properly in the discussion, but should also be included in the results section of the abstract.

Response: Thank you for the comment. Statement clarifying that the associated factors were significant when adjusted for the nonsignificant factors that were also included in the model.

Response for Reviewer 2 comments

R2: Contribution: Equal or unequal contribution should be explained at first page?

Response: Thank you. It is included now. All the authors contributed equally to this work.

R2: Style: Font style for title and headings should be adhered journal style?

Response: Thank you. Font styles are adhering to the journal style.

R2: Table 5. Cross tabulation for cases and controls should be included?

Response: Thank you, it is included now.

Submitted filename: Response to reviewers.docx

Click here for additional data file.

30 Jan 2020

Factors associated with intrauterine contraceptive device use among women of reproductive age group in Addis Ababa, Ethiopia: A case control study

PONE-D-19-22523R2

Dear Dr. Dereje,

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

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

With kind regards,

Catherine S. Todd

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

My thanks to the authors for addressing the remaining concerns from the reviewers and this manuscript is accepted. Upon acceptance, I would recommend professional editing as the manuscript would benefit from further grammatical and phrasing improvements in an effort to make the text more concise.

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: All comments have been addressed

**********

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

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

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

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

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

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

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

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

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

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

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: (No Response)

**********

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: Yes: Mengistu Meskele

3 Feb 2020

PONE-D-19-22523R2

Factors associated with intrauterine contraceptive device use among women of reproductive age group in Addis Ababa, Ethiopia: A case control study

Dear Dr. Dereje:

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