Prevalence and determinants of modern contraceptive utilization among women in the reproductive age group in Edaga-hamus Town, Eastern zone, Tigray region, Ethiopia, June 2017.

INTRODUCTION: All individuals and couples have a basic human right to decide freely and responsibly the number, spacing, and timing of their child. However, In Ethiopia, the prevalence of contraceptive utilization remains low and it varies in different regions. Therefore, this study was aimed to determine prevalence and determinant factors affecting the utilization of modern contraception in the reproductive age group (15-49 years) in Edaga-Hamus Town.
METHODOLOGY: A community based Cross-Sectional study was carried out on April 23 to May 10, 2017. A systemic random sampling method was used to select study participants. Information was collected using a structured, pre-tested questionnaire. The data were entered into EPI-info version 7.1 and imported to SPSS version 20. Summary statistics and logistic regression analysis were performed using SPSS version 20. Those variables having a P-value of less than 0.2 in the bivariable analysis were fitted in multivariable analysis. AOR with 95% CI and P-value<0.05 were used during multivariable analysis to identify the factors associated with the utilization of modern in reproductive. RESULT: In this study the overall prevalence of modern contraceptive utilization was 58.5%. Age (AOR = 0.406,95%,Cl: (0.000,0.398)), Educational status (AOR = 0.901,95% Cl (0.340,4.107)), Feeling of husband towards Modern contraceptive (AOR = 0.186, 95% CI (0.056,0.617) had protective effect of utilization of modern contraceptive. But Number of children 1-3 and 4-5 wanted(AOR = 10.802,95%(4.027,28.975)), AOR = 2.624,95% CI (1.437,4.791), was a risk for utilization of modern contraceptive. CONCLUSION AND RECOMMENDATION: The prevalence of Modern contraceptive utilization was still to be low (far below the national target). Therefore, providing educational opportunities, creating awareness about contraception and effective counseling would increase modern contraceptive methods utilization.

Introduction

According to the world health organization world statistics report, trends of maternal mortality rate are reduced from 385 to 216 globally, 538 to 176 in South Asia, 987 to 546 in sub-Saharan Africa and 1250 to 353 in Ethiopia from 1990 to 2015[1]. In developing regions the overall MMR is 239, which is nearly 20 times higher than that of developed regions[1]. Sub-Saharan Africa takes a very high maternal mortality rate[2]. Ethiopian Ministry of health has taken different types of an initiative to decrease maternal morbidity and mortality, like accessing Modern family planning service at health facilities throughout the country since 1980. According to the United Nations, official population estimates and projections in 2050 the world population will be in the range of 7.3 billion to 10.7 billion persons. About 96% of the total annual population increase occurs in less developed regions[2,3]. Around the world, about 222 million women have an unmet need for family planning and 645 million women have their needs met through the use of a modern contraceptive method, nine children under age 5 die in Africa which resulted in the death of 4.8 million children annually[4]. Sub Saharan Africa faces the most serious population and reproductive health challenges including the highest maternal mortality, population growth rate, total fertility rate and much unmet need for family planning in the world. Ethiopia is considered to be one of the most populous countries in Africa; only less than 23% of women in the reproductive age group are currently using contraception, which is still low to affect fertility following Nigeria and Egypt[5].

Modern contraceptive use by currently married Ethiopian women has steadily increased over the last 15 years, jumping from 6% of women using modern contraceptive method in 2000 to 35% in 2016, and the largest growth has been in injectables use, which expanded from use by 3% of women in 2000 to 23% in 2016, followed by growth in implant use, from less than 1% of women using in 2000 to 8% in 2016[6]. This has resulted in high rates of unwanted pregnancies, unplanned deliveries and unsafe abortions resulting in high maternal mortalities in the regions [2, 7–9].

In Ethiopia there is regional variation in modern contraceptive utilization; in Somali (1%), Afar (12%), Oromiya (28%), Benishangul-Gumuz(28%), Dire Dawa(29) Harari(29%) Gambela(35%), Tigray(35%), SNNPR(40%), Amhara(47%) Addis Ababa(50%)[6].

Study conduct in Ofla District, Tigray, Northern Ethiopia (37.1%)[10], in Tigray, North Ethiopia(35.6%)[11], in Humera town, Tigray Region, Ethiopia(27.1%)[12], in Tigray, Ethiopia(46%)[13], Addis Ababa (56.3%)[14], Debre Birhan district North Showa zone, central Ethiopia (46.9%)[15], Tigray region (32.5%)[16] and in Gondar town, northwest Ethiopia reported contraceptive utilization of 48.4 respectively[17].

Studies conducted in the Tigray region and other parts of Ethiopia showed factors found to be associated with the utilization of contraceptives vary. These include educational level, socio-cultural beliefs and practices, level of knowledge, myths, fear of side effects, partner's objection, convenience, fertility intentions, accessibility, providers' skill and competence, and other factors in the service area. These factors go a long way to influence the type of contraceptive one decides to use and use[18]. The finding of the mini EDHS 2016 (a UMC of 35.5%) for the Tigray region was striking and found to be lower than the UMC of other big regions of Ethiopia. Tigray region was believed to be one of the best performing regions as regards family planning service provision however the findings of the mini EDHS were to the contrary. This lead the Tigray regional health bureau to call and initiate the present study so that to verify the findings of the mini EDHS for the region. However, studies addressing the proportion of women utilizing modern contraceptives and its associated factors are limited in the study area.

Further, determining the prevalence and associated factors in the actual local setting is important to take appropriate and tailored interventions. Therefore this study was aimed at determining the prevalence and associated factors of modern contraceptive utilization among married women of the reproductive age group in Edaga hamus town.

Methodology

Study setting

A community-based cross-sectional study was conducted from April 23 to May 10, 2017, at Edagahamus city, Tigray regional state of Ethiopia. Edagahamus is founded in the eastern zone of Tigray, wereda Saesie Tsaida Amba; which is located 885 Km north of the Ethiopian capital city of Addis Ababa, 105 Km east of the Tigray capital city Mekelle and around 20 Km near to Adigrat. Edagahamus is divided into four kebeles and the total population was 21,993; from those 10,031 were male and 11,962 were female. There is only one health center in Edagahamus and 3 private clinics.

Participants

All women of reproductive age who reside in Edagahamus were taken as the study population. All women in the reproductive age group (15–49) are included, while women who were not mentally competent or who had any psychiatric disorders and critically ill during data collection were excluded.

Sample size determination

By taking into consideration, 35.2% of the prevalence of modern contraceptives in Tigray region, EDHS 2016[6]. 95% confidence level, 5% tolerable margin of error, possible nonresponse rate of 10%, a total sample of 386 was taken. To check for the adequacy of the sample size, Epi info was used by considering factors associated with modern contraceptive use. By comparing sample size based on a single population proportion formula and Epi-info, the sample size determined by the single population proportion was greater than that of the Epi-info. Therefore the largest sample size of 383 was taken.

The required sample size calculated using the formula Where n = sample size;

z = (1.96);

P = estimate of key proportion.

n = (1.96)2*0.352(1–0.352)/ (0.05*0.05) = 350.5~ 350.5 + 10% non response rate, the final n would be; 351+ 35 = 386

Sampling procedure

The probability sampling technique was employed. Edagahamus is divided into four kebeles then, the sample size was allocated to each selected kebeles proportionally based on their expected number of women in reproductive age in each kebeles. The study participant was selected by systematic random sampling method for the households every 8th household.

Study variables

Dependent variables

Modern contraceptive utilization.

Independent variables

Socio-demographic and economic variables, Reproductive history, Socio-psychological factors, Source of information, Knowledge, and Attitude of modern contraceptive.

Operational definition

Modern contraceptive methods: Including injectables, pills, implants, intrauterine contraceptive devices (IUCD), condoms, tubal ligation, and vasectomy.

Utilization: Using any of the above modern contraceptive methods to space the child and to protect unwanted pregnancy. Current use:—A woman who is using a modern contraceptive method at the time of the study. Ever user:—A woman who has practiced modern contraceptive methods sometime in the past but not using at the time of this study.

Knowledge of modern contraceptive methods:—According to this study if a woman mentions one of the modern contraceptive methods considers that she has good knowledge of modern contraceptive methods.

The attitude of modern contraceptives: was assessed by a Likert scale. Responses were dichotomized and summed. Having a positive response to at least 75% of statements was considered a positive attitude. Attitude statements included feelings towards the benefits of contraception (for both woman and family) and side effects.

Keble: A small administrative unite consisting of 20.000 population.

Data collection tools and techniques

Data was collected by using an interviewer-administered and structured questionnaire adapted from different similar research with modification according to the context of the study area. To establish face validity and translation quality the questionnaire was tested on 38 women in reproductive age in a similar village population from selected adjacent kebeles in the district by data collectors and supervisors during training. A few questions, language clarity and information were revised and the questionnaire was finalized for the study. The questionnaire includes socio-demographic, economic status, Reproductive history, Socio-psychological factors, Source of information and Knowledge of modern contraceptives.

Data quality assurance and control

Five health professional data collectors and two supervisors were recruited from the Health Center and they were given training for one day. The supervisors followed the process of data collection daily, checked the data completeness consistency and communicate with principal investigators daily.

Data processing and analysis

Data was coded, cleaned, recorded and entered Epi info 7and finally export to SPSS version 22.00 for analysis. Simple descriptive summary statistics were done. Tables, statements, charts, and graphs were used to present the result of the analyzed data. Associations between independent and dependent variables were analyzed first using bivariate logistic regression analysis. Variables that had p<0.2 on bivariate analysis were entered multivariable logistic regression analysis. After checking using chi-square test variables with small cell size were merged into related categories. Appropriate model diagnostics and goodness of fit tests were done. Multicollinearity was checked to test correlation among predictor variables and Hosmer and Lemeshow test P-value (>0.2) were conducted to see model fitness. The statistical association between the different independent variables about dependent was measured using OR, AOR, 95% CI and P-values <0.05 was considered statistically significant.

Ethical approval and consent to participate

Ethical clearance was obtained from the Ethical Review Board of Adigrat University, College of Medicine and Health Sciences and it is also got granted from the Health office of Adigrat hospital. Verbal and written consents were obtained after explaining their full right to refuse, withdraw any time, without any explaining or giving reasons. Information's obtained from individuals’ participants was kept secure and confidential. Names and other identifying data of respondents were made by using code throughout the study process to obtain confidentiality. Finally, data were collected according to the standard questionnaire prepared.

Results

Socio-demographic characteristics

A total of 383 Reproductive age group women participated in a response rate of 100%. Out of the total participated women, 64 (16.7%) were with an age range of 15–19 years. Nearly half of 163 (42.6%) participants were housewives. (Table 1, Figs 1, 2 and 3).

Table 1

Characteristics of participants in the study of contraceptive utilization at Edagahamus, northern Ethiopia, 2017.

Socio- demographic and economic factors	Frequency	Percent (%)
Age
15–19	55	14.4
20–24	96	25.1
25–29	80	20.9
30–34	83	21.7
35–39	23	6.0
40–44	34	8.9
45–49	12	3.1
Ethnicity
Tigray	344	89.9
Afar	35	9.1
Amhara	4	1
Religion
Orthodox	329	85.9
Muslim	48	12.5
Protestant	3	0.8
Catholic	3	0.8
Occupational status
Housewife	163	42.6
Merchant	129	33.7
Governmental employee	28	7.3
Student	40	10.4
Farmer	2	0.5
daily labor	21	5.5

Fig 1

Educational status of women in reproductive age.

Fig 2

Educational status of husband.

Fig 3

Marital status of women of reproductive age.

Reproductive characteristics

Nearly three fourth of the respondents (74.4%) reported that they had a pregnancy. Among them, 96.1% of these pregnancies were wanted. Most of the respondents (46.5%) had 1–2 live births, 81 (28.9%) had 3–4 live birth and 70 (24.6%) had 5 and above live birth. One hundred seventy-seven (30.54%) of women respond it could be that too many children can improve family income. (Table 2).

Table 2

Characteristics of participants in the study of contraceptive utilization at Edagahamus, northern Ethiopia, 2017.

Reproductive factor	Frequency	Percent (%)
Having any pregnancy before
Yes	285	74.4
No	98	25.6
Were pregnancy wanted
Yes	274	96.1
No	11	3.9
No. of live births
1–2	132	46.5
3–4	81	28.9
5 and above	70	24.6
No. Of living children
1–2	130	46.1
3–4	90	31.9
5 and above	62	22
History of abortion
Yes	74	26
No	211	74
Type of abortion
Induced	11	14.9
Spontaneous	63	85.1
Respondents age at first pregnancy:
<18	113	39.6
18 and above	172	60.4
Children desired to you have
1–3	34	8.9
4–5	212	55.4
6 and above	137	35.8
Having too many children help to improve the income of the family
Yes	117	30.5
No	266	69.5
Having too many children guarantee generational continuity
Yes	173	45.2
No	210	54.8
Should child mortality have compensated by too much birth
Yes	128	33.4
No	255	66.6
Is it a sin to practice MC method
Yes	138	36
No	245	64
Does child spacing help to the health of the mother and child
Yes	342	89.3
No	41	10.7
MC has side effect will be it dangerous to the mother
Yes	188	49.1
No	191	49.9
I do not know	4	1
Does contraceptive use decrease sexual satisfaction
Yes	69	18
No	272	71
I do not know	42	11
Does contraceptive cause infertility in women
Yes	136	35.5
No	221	57.7
I do not know	26	6.8
Should men share responsible for FP use
Yes	282	73.6
No	101	26.4

Knowledge on modern contraceptive

In our study, all respondents heard about modern contraceptives. Among all respondents, most of the information about contraceptives got from health institution i.e. 220.199, 183, 48,176 of the respondents also get the information from radio, television, newspaper, and friend (neighborhood) respectively. About knowledge the different types of modern contraceptive 345 of the respondents knew pills, 364 knew injectable, 261 knew implant, 199 knew condom, 173 knew IUCD. Generally, 73.6% of the respondents had good knowledge while the rest were poor. Regarding number 58(15.2%) of respondents knew with the interval of 1–2, 223(58.2) knew from 3–4 number of contraceptives and 102(26.6%) knew 5 and above (Table 3, Fig 4).

Table 3

Knowledge of participants in the study of modern contraceptive utilization at Edagahamus, northern Ethiopia, 2017.

Variables	Frequency	Percent (%)
Have you heard about contraceptive
Yes	383	100
No	0	0.0
Source of information
Radio	199	52%
Television	183	47.8%
Newspaper	48	12.5
Health institution	220	57.4
Friend (neighborhood)	176	46%
Types of contraceptive you know
Pill	345	90.1%
Injectable	364	95%
Implant	261	68.1%
IUCD	173
Condom	199	52%
How many MC do you know
1–2	58	15.2
3–4	223	58.2
5 and above	102	26.6

Fig 4

The source of contraceptive.

Attitude of women towards using modern contraceptives

As regards to attitude of women on using modern contraceptive two hundred forte three (63.4%) of respondents had a positive attitude respectively. Among non-users the reason included where fear of side effect (4.4%), disagreement with the husband (2.5%), religious reason (3.2%), community reason(0.6%) and other(89.3%)(separation). In our study among the participants, 254(66.3%) of the participants were respond that yes for cultural acceptance of the utilize of modern contraceptives by the community and 129(33.7%) of them respond no for cultural acceptance. (Table 4)

Table 4

Attitude of women towards using modern contraceptives at Edagahamus, northern Ethiopia, 2017.

Variables	Frequency	Percent (%)
Do you use any method of MC
Yes	224	58.5
No	159	41.5
If no why
Fear of side effect	7	4.4
Disagreement with husband	4	2.5
Religious reasons	5	3.2
Community reason	1	0.6
Other	142	89.3
Cultural acceptance
Yes	254	66.3
No	129	33.7
Religious fathers' acceptance
Yes	13	3.4
No	370	96.6
Feeling of husband
Positive	151	62.1
Negative	42	17.3
Nothing	50	20.6
Communication with husband MC
Sometimes	76	30.4
Always	107	42.8
No communication	67	26.8
Weakness observed so far
shortage of contraceptive	2	0.9
shortage of health professional	4	1.8
poor client approach	17	7.5
no weakness	203	89.8

Modern contraceptive utilization

Overall prevalence of modern contraceptive utilization in Edagahamus town was found to be two (58.5%). Majority of the contraceptive ever used 121 (54.4%) use injectable contraceptive methods followed by pills 33 (14,7) and implants 31 (13.5%) respectively. (Figs 5 and 6).

Fig 5

Type of contraceptive ever used.

Fig 6

Currently used contraceptive.

Factors affecting modern contraceptive utilization among reproductive women

Age, Educational status of the husband, Number of children wanted and Communication with the husband of MC have significantly associated with modern contraceptives in Edagahamus. Women in the age group of 25–29 years were 59.4% (AOR = 0.406; C1 = 0.000, 0.398; P = .017) times less likely to use modern contraceptives as compared to those age group of 15–19 years. The odds of the utilization of modern contraceptives in the study area were 86.5% times (AOR = 0.135; 95% C1 = 0.002, 0.760; P = .033) less likely to use MC among 30–34 years as compared to women of 15–19 Years of age.

The odds of the utilization of modern contraceptive among education status of an illiterate husband were 99.7% times less likely to use than whose educational status 9–12 (AOR = 0.003;95%CI = 0.000,0.316;P = 0.014*) and Illiterate were 99.6% less to use than diploma and above(AOR = 0.004;95%CI = 0.000,0.631;P = 0.032). However, women who want to have number of children 1–3 were 10.8 times more likely to used modern contraceptive than who want 6 and above children (AOR = 10.802; 95%CI; 4.027, 28.975;P = 0.000) and women who want to have 4–5 were 3 times more likely to practice modern contraceptive than who want to have 6 and above (AOR = 2.624;95%CI = 1.437,4.791;P = 0.002).

A woman whose husband who had a negative feeling towards the utilization of modern contraceptive was 0.814 times less likely to use modern contraceptive than who had a positive feeling (AOR = 0.186;95%CI = 0.056,0.617; P = 0.006) (Table 5).

Table 5

Bi variable and multivariable logistic regression model for factors associated with contraceptive utilization at Edagahamus, northern Ethiopia, 2017.

Variable	Modern contraceptive use		COR (95% CI)	AOR
	yes	no
Age in years
15–19	9	46	1	1
20–24	66	30	0.089, (0.039,0.205)*	0.055(0.003,1.081)
25–29	77	3	0.008(0.002,0.03)*	0.406(0.000,0.398)*
30–34	59	24	1.152(0.21,0.133)	0.135(0.002,0.760)*
35–39	9	14	0.210(0.92,0.481)	0.069(0.002,2.591)
40–44	2	32	0.250(0.98,0.639)	1.575(0.000,6.693)
45–49	2	10	0.667(0.177,2.513)	0.742(0.003,17.124)
Educational status
Illiterate	5	30	1	1
Can read write	2	3	0.250(0.033,1.893)*	0.681(0.000,5.995)
1–4	17	6	0.059(0.016,0.222)*	0.52(0.14,17.984)
5–8	31	30	0.161(0.161,0.056)*	0.293(0.008,10.443)
9–12	81	76	0.156(0.058,0.424)*	0.822(0.021,31.926)
Diploma and above	88	14	0.027(0.009,0.080)*	0.901(0.340,4.107)
Educational status of husband
Illiterate	5	35	1	1
Can read and write	2	20	1.389(0.247,7.823)	5.702(0.569,5.709)
1–4	8	15	0.089(0.025,0.313)*	1.767(0.67,39.845)
5–8	49	13	0.045(0.015,0.136)*	0.074(0.003,1.949)
9–12	54	7	0.025(0.008,0.081)*	0.003(0.000,0.316)*
Diploma and above	63	2	0.005(0.001,0.025)*	0.004(0.000,0.631)*
Marital status
Unmarried	24	105	1	1
Married	179	24	0.032(0.008,0.124)*	0.000(0.000,)0.999
Divorced	18	22	1.193(0.309,4.609)	0.000(0.000,)0.999
Widowed	3	11	0.333(0.081,1.380)*	0.000(0.000,)0.999
Occupational status
Housewife	100	63	1	1
Merchant	87	42	0.766(0.472,1.244)	0.348(0.054,2.228)
Government employee	21	8	0.605(0.523,1.448)	2.682(0.029,24.796)
Student	6	34	8.995(3.572,22.647)*	2.950(0.000,9.838)
Daily labor	10	12	1.905(0.777,4.668)*	0.007(0.000,3.180)
Income
<600	99	97	1	1
600–1200	61	42	0.703(0.434, 1.139 )*	0.127(0.011, 1.523)
>1200	64	20	0.319(0.1790.567,) *	0.595(0.072,4.938)
Have any pregnancy
Yes	190	95	1	1
No	34	64	3.765(2.322,6.105) *	0.852(0.090,8.046)
Number of pregnancies
1–2	76	47	1	1
3–4	58	25	0.697(0.385,1.262)	0.797(0.423,1.501)
5 and above	56	21	0.664(0.362,1.218)*	1.191(0.590,2.402)
Number of children wanted
1–3	16	18	10.362(4.661,22.088)*	10.8(4.027,28.975)*
4–5	116	96	3.910(2.430,6.318)*	2.624(1.437,4.791)*
6 and above	92	45	1	1
Feeling of the husband towards MC
Negative	40	64	1	1
Positive	163	26	0.036(0.013,0.095)*	0.186(0.056,0.617)*
Nothing	48	42	1.145(0.456,2.876)	0.036(0.005,1.233)
Communication with the husband of MC
Sometimes	90	36	0.113(0.053,0.243)*	0.300(0.070,1,288)
Always	125	23	0.008(0.002,0.036)*	3.176(0.894,11.279)
No communication	40	69	1	1

Note: *-significant results, 1-reference category **p-value<0.001, *p-value≤0.05

Discussions

This study was conducted to assess the Prevalence and determinants of modern contraceptive utilization among Women in the Reproductive Age Group in Edaga-hamus Town, Eastern zone, Tigray Region, Ethiopia. In this study, the current prevalence of modern contraceptive utilization was 58.5%. The result is in line with the study conduct in Addis Abeba (56.3%) and Lusaka, Zambia (59.2%) [6, 14, 19]. The variations may be due to different population characteristics. However, the prevalence of modern contraceptive utilization in this study was higher than the study conduct in Ofla District, Tigray, Northern Ethiopia (37.1%) [10], in Tigray, North Ethiopia(35.6%) [11], in Humera town, Tigray Region, Ethiopia(27.1%) [12], in Tigray, Ethiopia(46%) [13], in South Nigeria (21.6%) [20]. United Nations millennium development goal (MDG) 2015 report for African continent (33.4%) [2], and the 2015 sub-Saharan MDG reports [2]. 2016 Ethiopian DHS for Amhara region, 46.9% [9], Gondar, Nekemte [21], Debreberhan [15], and west Gojjam [22], Ghana [22, 23], Kenya [2] and Nepal [24]. The United Nations MDG 2015 report for Somalia, Eritrea, and South Sudan which was 23.7, 20 and 6.8% respectively [2]. This difference might be because of socio-demographic and cultural variation. Besides, there is a difference in the study time interval between other studies done and this study. Moreover, the discrepancy may be due to an educational grade of study participants, up-to-date house to house health education policy by HEW more organized in the town through the Ethiopian federal ministry of health. However, this result is lower than the results in Benin City, Nigeria (64.5%) [25], Holeta town (73%) [5], Mbarara, Uganda (85%)%) [26], and Lesotho (82–86%)%) [26, 27], respectively. This discrepancy might be due to the age difference or and religion of the participant and the other reason might be due to geographical variation. The commonest modern contraceptive method utilizing by up-to-date married men wife was injectables (54.4%), pills (14.7%) and implants (13.5%) married men were male condoms (2.2%) this is similar with study conduct in Holeta town [5], (injectable 48% followed by implant 15.3% and pill 5.4%. This showed they were aware of family planning and they knew the different methods. This study revealed that the odds of those age 15–19 years were less likely to use modern contraceptives by 59.4% and 86.5% as compared to age 25–29 and 30–34 years. This study similar to study conduct in Ethiopia demographic and health survey, 2016 [6] and contrary with study conduct in shire Endaslasie [28]. This may be due to those who are 15–19 where most of them were unmarried but those 25–29, 30–34 were most of them are married and within this range of age, their educational status was high. Mother who had negative husband approval towards modern contraceptive utilization were 81% less likely to use MC than who approve it positive husband approval. This finding of the study was supported by study conduct in Farta district south Gondar in 2014 [29]. This might be due to the educational status of husbands who had high educational status were good approval towards modern contraceptives. The odds of the utilization of modern contraceptive among education status of an illiterate husband were 99.7% times less likely to use than whose educational status 9–12 (AOR = 0.003;95%CI = 0.000,0.316;P = 0.014*) and Illiterate were 99.6% less to use than diploma and above (AOR = 0.004;95%CI = 0.000,0.631;P = 0.032). This agreed with the studies conducted in most developing countries [17, 21, 22]. This can be explained by the notion that women with better educational levels have better access to health care information, have greater autonomy to make decisions and have a greater ability to use quality health care services [30, 31]. In this study mother who went to have several children, 1–3 and 4–5 were eleven and three times more likely to used modern contraceptive than who went 6 and above children. It might be to attain their desired number of children and the spacing and timing of their births. This finding is similar to previous reports from Zambia, Northwest Tigray and Uganda which reported that as the number of living children increases, the use of modern contraceptive increases [15, 19, 26].

Limitation

Since this study was limited to married women only at the time of the study; results may not be generalized to all women in Edagahamus town.

The study design is cross-sectional; therefore it may be difficult to establish a temporal relationship.

Conclusion and recommendation

Modern contraceptive utilization was still low (far below the national target). Factors such as age, educational status of the husband, the number of children wanted and feeling of the husband was associated with the utilization of modern contraceptive. Therefore, train health professionals especially health extension workers to raise awareness education, enhance information, education and communication activities regarding modern contraceptives and create awareness about the quality of life and healthy live hood to the community through the training of health professionals to convince the community.

Questionnaire English version.

(DOCX)

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Questionnaire in local language.

(DOCX)

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Data set.

(SAV)

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27 Sep 2019

PONE-D-19-24295

Prevalence and determinants of modern contraceptive utilization among Women in the Reproductive Age Group in Edaga-hamus Town, Eastern zone, Tigray Region, Ethiopia, June 2017.

PLOS ONE

Dear Mr Gebremeskel

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.

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

It is very important topic particularly for policy developers and decision maker in the region and nationally at large. I would like to thank you all for dedicating your time to be part of the solution.

Being said all these here are some of my opinion and feedbacks regard to your work. In general, the paper still more look like a thesis than a manuscript. It needs a major reform and modification from abstract to the final conclusion.

Abstract:

The introduction and objective part need to be merged and try to make as brief as possible at least to deliver the right message. The methods is disorganized. It looks more like a copy and paste from the original thesis. The result and conclusion might need some change and more focus on the relevant result to convey the right information to readers.

Introduction:

It has tried to demonstrate the broad area of contraceptive from global to national and regional perspective. However, since this topic is one of the most studied topic in Ethiopia I believe you would have gotten more literature that could be included and provide profound insight for your work. I am a bit surprised the literature included in this section very limited and out dated, at the same time, not included studies that has been conducted in Tigery region. As to my knowledge enormous studies has been carried out the last ten years in Tigery and other part of Ethiopia, which have helped the effective implementation of the national contraceptive program. I, therefore, would like to recommend you to include those up to date studies for the credibility of your work, since most of the literature included in this section a bite old and insignificant for the area of the study.

Methods:

As I mentioned above, this paper more looks like a thesis and you need to revise each and every section. The sample size determination not clear. You have said a sample size of 383 was determined by using sample size formula. What does this mean? What kind of sample size formula did you employee? Why you choose probable sampling technique to select study participant? You indicated modern contraceptive utilization is the dependent variable, but you have tried to defined utilization only. You must define the right variable that would help you clarify in the result section. You need to vividly define the dependent and independent variables clearly. How do you measure you dependent variable? There is no single sentence that shows how you measure depend variable. How did you measure the validity and reliability of your data collection tools? All these and others will spark additional questions if you don’t address these and associated issues come with the methods section.

Result:

How did you manage to get a 100% respond rate? On the knowledge, attitude and practice subtopic, it is not clear how you measure knowledge, attitude and practice. You need to show clearly how knowledge is measured in this study. Overall, this section needs major revision, it seems to have a jargon of information with no direction. I recommend you to start the major revision at the method section, in order to be able to have a clear answer for the questions would arises associate to your analysis.

Discussion:

It is admirable to observe you have tried to make argument based on comparison with similar study conducted at various places. As I have mention above due to insufficient literature, especially excluding those studies carried out at local and national level, the arguments you laid out appears to be very shallow and weak. Moreover, you have not discuss or made argument on the results indicated on the result section that makes the argument weak. You must discuss based on the findings of this study. You argument also must be supported by scientific studies.

Conclusion:

This section is so weak and frail. It doesn’t even show the major finding in this study.

In general, the manuscript lacks consistence, incoherence and disorganize. The entire section needs further revamp and more work to make the manuscript sound and informative.

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

We would appreciate receiving your revised manuscript by Nov 11 2019 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.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

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'.

A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

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,

Solomon Assefa Woreta

Academic Editor

PLOS ONE

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When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Thank you for including your ethics statement:

"Ethical clearance was obtained from the Ethical Review Board of ADU, College of Medicine and Health Sciences and it is also got granted from the Health office of Adigrat hospital. Verbal and written consents were obtained after explaining their full right to refuse, withdraw any time, without any explaining or giving reasons. Information's obtained from individuals’ participants was kept secure and confidential. Names and other identifying data of respondents were made by using code throughout the study process to obtain confidentiality. Finally, data were collected according to the standard questionnaire prepared.".

i) Please amend your current ethics statement to include the full name of the ethics committee/institutional review board(s) that approved your specific study.

ii) Once you have amended this/these statement(s) in the Methods section of the manuscript, please add the same text to the “Ethics Statement” field of the submission form (via “Edit Submission”).

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3. We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.

Whilst you may use any professional scientific editing service of your choice, PLOS has partnered with both American Journal Experts (AJE) and Editage to provide discounted services to PLOS authors. Both organizations have experience helping authors meet PLOS guidelines and can provide language editing, translation, manuscript formatting, and figure formatting to ensure your manuscript meets our submission guidelines. To take advantage of our partnership with AJE, visit the AJE website (http://learn.aje.com/plos/) for a 15% discount off AJE services. To take advantage of our partnership with Editage, visit the Editage website (www.editage.com) and enter referral code PLOSEDIT for a 15% discount off Editage services.  If the PLOS editorial team finds any language issues in text that either AJE or Editage has edited, the service provider will re-edit the text for free.

Upon resubmission, please provide the following:

The name of the colleague or the details of the professional service that edited your manuscript

A copy of your manuscript showing your changes by either highlighting them or using track changes (uploaded as a *supporting information* file)

A clean copy of the edited manuscript (uploaded as the new *manuscript* file)

4. We noticed minor instances of text overlap with the following previous publication(s), which need to be addressed:

https://globaljournals.org/GJMR_Volume13/4-Prevalence-and-Associated-Factors.pdf

https://www.longdom.org/open-access/prevalence-and-associated-factors-of-modern-contraceptive-utilization-amongmarried-women-in-reproductive-age-group-in-misha-woreda-2167-0420-1000372.pdf

https://jbino.com/docs/Issue03_04_2014.pdf

The text that needs to be addressed involves the Introduction (first 2 references) and the Abstract (bottom reference).

In your revision please ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed.

5. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

6. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants. Please ensure you have provided sufficient details to replicate the analyses such as: a) the recruitment date range (month and year), b) additional details describing any inclusion/exclusion criteria that were applied to participant recruitment, d) a statement as to whether your sample can be considered representative of a larger population, e) a description of how participants were recruited, and f) descriptions of where participants were recruited and where the research took place.

7. Thank you for stating the following in the Acknowledgments Section of your manuscript:

"Adigrat University was our fund agent to conduct this study. The role of Adigrat University was

providing appropriate training to develop the proposal, funding money to our data collectors and

following how the study is going on, finally, our University provides us basic training which was

helpful for our study."

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

"The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

Additional Editor Comments (if provided):

It is very important topic particularly for policy developers and decision maker in the region and nationally at large. I would like to thank you all for dedicating your time to be part of the solution.

Being said all these here are some of my opinion and feedbacks regard to your work. In general, the paper still more look like a thesis than a manuscript. It needs a major reform and modification from abstract to the final conclusion.

Abstract:

The introduction and objective part need to be merged and try to make as brief as possible at least to deliver the right message. The methods is disorganized. It looks more like a copy and paste from the original thesis. The result and conclusion might need some change and more focus on the relevant result to convey the right information to readers.

Introduction:

It has tried to demonstrate the broad area of contraceptive from global to national and regional perspective. However, since this topic is one of the most studied topic in Ethiopia I believe you would have gotten more literature that could be included and provide profound insight for your work. I am a bit surprised the literature included in this section very limited and out dated, at the same time, not included studies that has been conducted in Tigery region. As to my knowledge enormous studies has been carried out the last ten years in Tigery and other part of Ethiopia, which have helped the effective implementation of the national contraceptive program. I, therefore, would like to recommend you to include those up to date studies for the credibility of your work, since most of the literature included in this section a bite old and insignificant for the area of the study.

Methods:

As I mentioned above, this paper more looks like a thesis and you need to revise each and every section. The sample size determination not clear. You have said a sample size of 383 was determined by using sample size formula. What does this mean? What kind of sample size formula did you employee? Why you choose probable sampling technique to select study participant? You indicated modern contraceptive utilization is the dependent variable, but you have tried to defined utilization only. You must define the right variable that would help you clarify in the result section. You need to vividly define the dependent and independent variables clearly. How do you measure you dependent variable? There is no single sentence that shows how you measure depend variable. How did you measure the validity and reliability of your data collection tools? All these and others will spark additional questions if you don’t address these and associated issues come with the methods section.

Result:

How did you manage to get a 100% respond rate? On the knowledge, attitude and practice subtopic, it is not clear how you measure knowledge, attitude and practice. You need to show clearly how knowledge is measured in this study. Overall, this section needs major revision, it seems to have a jargon of information with no direction. I recommend you to start the major revision at the method section, in order to be able to have a clear answer for the questions would arises associate to your analysis.

Discussion:

It is admirable to observe you have tried to make argument based on comparison with similar study conducted at various places. As I have mention above due to insufficient literature, especially excluding those studies carried out at local and national level, the arguments you laid out appears to be very shallow and weak. Moreover, you have not discuss or made argument on the results indicated on the result section that makes the argument weak. You must discuss based on the findings of this study. You argument also must be supported by scientific studies.

Conclusion:

This section is so weak and frail. It doesn’t even show the major finding in this study.

In general, the manuscript lacks consistence, incoherence and disorganize. The entire section needs further revamp and more work to make the manuscript sound and informative.

[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: Partly

**********

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

Reviewer #1: No

Reviewer #2: Yes

**********

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: No

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: 1. There are abbreviations in the “abstract” section but there shouldn’t be abbreviations in the abstract. In the other sections of the manuscript, you need to write the full phrase before abbreviation.

2. There is spelling, grammar problems e.g. In the abstract under “objective” you state “stud” instead of “study”. Please revise the whole manuscript to correct such errors.

3. The adjusted odds ratio for educational status in the abstract section is 0.901 and the 95%Cl is 1.340, 4.107. The AOR is out of the 95% CI which is incorrect. I suggest the authors to revise all AOR and their 95%CI.

4. The conclusion and recommendations are very vague and they are not based on the findings of the study.

5. In the introduction part, the gap is not clearly stated and how your study is going to help to address the gap/s. please use recent finding in the introduction section.

6. Please include exclusion criteria.

7. Put the necessary formula and steps of sample size determination. The reference cited to calculate sample size is for oromia not for Tigray region. Revise this.

8. Please include how you identified households with reproductive age women.

9. Please revise variables, data collection tools and techniques, data quality control, data analysis and others. Please read the author information of this journal and follow it.

10. In the analysis, did you check multi-collinearity, model goodness of model? Please include this.

11. In the result section, there are grammar problems, citation of tables and figures need revision.

12. Revise all tables especially the table for the result of logistic regression. What dose * mean?

13. The discussion needs revision. Synthesize the result of other study findings and discuss the implications of your study findings.

14. Please revise the limitation. It has two similar sentences.

15. Revise the references

Reviewer #2: General comments for the manuscript:

The comments are not limited to the summary bellow (there are comments in the pdf; the author can click on each sticky note to see the comments)

Introduction part:

Grammar, logical flow and focus problems

Methods part:

I have hesitation on sampling method, inclusion criteria versus sampling procedure and sample size calculation seems wrong.

Some meaningless phrases and initial words need capitalization

Result part:

The measurement of knowledge and attitude is not correct

The interpretation of the association is not clear and authors may not understand the reference variables

Different font size, repetition of words, wrong quantifiers, inclusion of study time in title of tables, and wrong grammars are there.

Discussion part:

Some incomparable and less justified differences

Some need of re writing

Difficult to differentiate result and discussion (especially at the last paragraph of the discussion)

**********

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: No

[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: 2. Manuscript Reviewed PONE-D-19-24295_reviewer.pdf

Click here for additional data file.

14 Oct 2019

on time feed back

Submitted filename: reviwer comment.docx

Click here for additional data file.

17 Oct 2019

PONE-D-19-24295R1

Prevalence and determinants of modern contraceptive utilization among Women in the Reproductive Age Group in Edaga-hamus Town, Eastern zone, Tigray Region, Ethiopia, June 2017.

PLOS ONE

Dear Mr.Teferi Gebru Gremeskel,

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.

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

Thank you again for trying to incorporate the comments provided before. There are still several points you need to address to proceed to next level. Here are some of my comments and suggestions you need to pay attention.

Abstract:

The introduction in the abstract section should be revised again. It has inconclusive and fragmented information. Similarly, you need to rewrite the conclusion in this section. “Modern contraceptives found below”. What does this means? You have gotten similar such meaningless paragraphs throughout the manuscript that needs immediate corrective action.

Introduction:

As I have tried to indicate on the previous comment the literatures used in the introduction were very out dated and I can say some of them not correctly cited, for instance, the population of Ethiopia in the year 2017 was 105 million according to Ethiopian Demographic Survey and other sources, however, in your case looks below the true number. At least you need to include literatures that is relevant for the discussion.

Methods:

Operation definition for Knowledge and attitude looks like explanation after analysis. I recommend you to write a definition employed before you got started the research. So that, you could have a clear definition for knowledge and attitude.

Result:

This section still have several redundancy and inconsistencies. I recommend you to evaluate critically and correct each and every statements to give meaningful information. For instance, you began the statement with “some of the respondents (74.4%) reported that they had pregnancy while 98 (25.6%) had no pregnancy”.  What is the number for some of the respondents???

Why you choose to write both pregnant and non-pregnant at the same time. It is obviously known the number of non-pregnant women if you mentioned the pregnant women in your analysis. Which have in fact created redundancy in your paragraphs.

Discussion:

This section still needs strong argument based on clear scientific evidence. At the same time, you must address all the variables analyzed in this study. There are plenty of research articles published in various region of Ethiopia which would be very helpful to make a strong point to compare with your findings. However, the literature employed in this section appears very scanty and shallow for comparison. On the other hand, the limitation that has been indicated is not clear. Why children ????? What is the reference is all about….???? You need to have a good explanation for that…..?????

Conclusion:

You need to correct the first sentences.” Modern contraceptive utilization was found below.” What kind of message do you really want to convey??

Final note:

Before resubmitting the manuscript again you must critically evaluate each section and read similar articles that has been published, therefore, you can see the shortcoming of this research and would help you bridge the gap already existed in this manuscript.

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

We would appreciate receiving your revised manuscript by Dec 01 2019 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.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

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'.

A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

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,

Solomon Assefa Woreta

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Thank you again for trying to incorporate the comments provided before. There are still several points you need to address to proceed to next level. Here are some of my comments and suggestions you need to pay attention.

Abstract:

- The introduction in the abstract section should be revised again. It has inconclusive and fragmented information. Similarly, you need to rewrite the conclusion in this section. “Modern contraceptives found below”. What does this means? You have gotten similar such meaningless paragraphs throughout the manuscript that needs immediate corrective action.

Introduction:

- As I have tried to indicate on the previous comment the literatures used in the introduction were very out dated and I can say some of them not correctly cited, for instance, the population of Ethiopia in the year 2017 was 105 million according to Ethiopian Demographic Survey and other sources, however, in your case looks below the true number. At least you need to include literatures that is relevant for the discussion.

Methods:

- Operation definition for Knowledge and attitude looks like explanation after analysis. I recommend you to write a definition employed before you got started the research. So that, you could have a clear definition for knowledge and attitude.

Result:

- This section still have several redundancy and inconsistencies. I recommend you to evaluate critically and correct each and every statements to give meaningful information. For instance, you began the statement with “some of the respondents (74.4%) reported that they had pregnancy while 98 (25.6%) had no pregnancy”. What is the number for some of the respondents???

- Why you choose to write both pregnant and non-pregnant at the same time. It is obviously known the number of non-pregnant women if you mentioned the pregnant women in your analysis. Which have in fact created redundancy in your paragraphs.

Discussion:

- This section still needs strong argument based on clear scientific evidence. At the same time, you must address all the variables analyzed in this study. There are plenty of research articles published in various region of Ethiopia which would be very helpful to make a strong point to compare with your findings. However, the literature employed in this section appears very scanty and shallow for comparison. On the other hand, the limitation that has been indicated is not clear. Why children ????? What is the reference is all about….???? You need to have a good explanation for that…..?????

Conclusion:

- You need to correct the first sentences.” Modern contraceptive utilization was found below.” What kind of message do you really want to convey??

Final note:

Before resubmitting the manuscript again you must critically evaluate each section and read similar articles that has been published, therefore, you can see the shortcoming of this research and would help you bridge the gap already existed in this manuscript.

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

[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.

19 Oct 2019

on time feed back

Submitted filename: 2 Respond to comment..docx

Click here for additional data file.

7 Nov 2019

PONE-D-19-24295R2

Prevalence and determinants of modern contraceptive utilization among Women in the Reproductive Age Group in Edaga-hamus Town, Eastern zone, Tigray Region, Ethiopia, June 2017.

PLOS ONE

Dear Mr, Teferi Gebru,

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.

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

Thank you again for your dedication to improve this manuscript. I have noticed the effort you have put together to incorporate comments and suggestions that have been given by the reviewers. Despite the fact that you have worked to improve the manuscript, there are still comments and feed backs that you need to address before we move forward to the next step. Please try to read similar published articles to identify the gaps existed in this manuscript and bridge the gap.  At the meantime, make sure you encompass the comments that have been given by the reviewers. Please look back the following issues take appropriate corrective action.

Abstract:

This section has improved at many perspective. However, the conclusion and recommendation very shallow. Make sure your conclusion and recommendation must be drawn based on the result.

Methods:

The operation definition that has been given for attitude still needs further detail. What is about the mean? What is your cut off point? How you draw the mean?

Result:

Use appropriate topic; for instance, it isn’t clear why you used “Reproductive related and socio-psychological variable”. Make sure you choose representative subtopic than inscribing non-sense phrases. On top of this separate Knowledge and attitude, since both are different variable.

Discussion:

You need to remove the first paragraph that depicts the modern contraceptive and purpose of the study. I don’t see any relevance.  As I have tried to mention on my last comment, the argument on each topic need to be drawn based on evidence not based on your general knowledge. For instance, you mentioned “Mothers have several children, 1-3 and 4-5 were eleven and three times more likely to used modern contraceptive than who went 6 and above children. It might be to attain their desired number of children and the spacing and timing of their births.” You need to find a proper citation that supports your argument.

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

We would appreciate receiving your revised manuscript by Dec 22 2019 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.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

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'.

A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

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,

Solomon Assefa Woreta

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Thank you again for your dedication to improve this manuscript. I have noticed the effort you have put together to incorporate comments and suggestions that have been given by the reviewers. Despite the fact that you have worked to improve the manuscript, there are still comments and feed backs that you need to address before we move forward to the next step. Please try to read similar published articles to identify the gaps existed in this manuscript and bridge the gap. At the meantime, make sure you encompass the comments that have been given by the reviewers. Please look back the following issues take appropriate corrective action.

Abstract:

This section has improved at many perspective. However, the conclusion and recommendation very shallow. Make sure your conclusion and recommendation must be drawn based on the result.

Methods:

The operation definition that has been given for attitude still needs further detail. What is about the mean? What is your cut off point? How you draw the mean?

Result:

Use appropriate topic; for instance, it isn’t clear why you used “Reproductive related and socio-psychological variable”. Make sure you choose representative subtopic than inscribing junky phrases. On top of this separate Knowledge and attitude, since both are different variable.

Discussion:

You need to remove the first paragraph that depicts the modern contraceptive and purpose of the study. I don’t see any relevance. As I have tried to mention on my last comment, the argument on each topic need to be drawn based on evidence not based on your general knowledge. For instance, you mentioned “Mothers have several children, 1-3 and 4-5 were eleven and three times more likely to used modern contraceptive than who went 6 and above children. It might be to attain their desired number of children and the spacing and timing of their births.” You need to find a proper citation that supports your argument.

[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 #2: All comments have been addressed

Reviewer #3: (No Response)

**********

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

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

Reviewer #2: Partly

Reviewer #3: No

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

Reviewer #2: Yes

Reviewer #3: No

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

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

Reviewer #2: Yes

Reviewer #3: Yes

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

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

Reviewer #2: No

Reviewer #3: No

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6. Review Comments to the Author

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

Reviewer #2: General comments for the manuscript:

The comments are not limited to the summary bellow (there are comments in the pdf; the author can click on each sticky note to see the comments)

Abstract:

1. The prevalence is low --- so need to give emphasis for several children --- senseless

2. Needs to determine the associated factors

Introduction part:

The use of abbreviation without first use of full text is uncommon, which is not corrected from the previous comment

Methods part:

1. Using manual, the sample size is not correct, See the formula, but the result is still 385.5

2. Advice: Logically - first assumption, then formula and result is better, and even the first statement is enough for manuscript.

3. The variable practice is still not clear. Because utilization is outcome variable and practice of modern contraceptive is utilization. I don't know, what do the author what to say?----which is not corrected from the previous comment

Result part:

1. Measurement of attitude is not corrected from the previous comment. 58.5% utilizer means not attitude.

2. Diploma and above variable has a p value of 0.104 under the AOR column. it is clear that there is no association in this variable

3. Advice: please use the correct reference variable.

Discussion part:

1. In discussion, the values could not be included, otherwise there is no difference between result and discussion, which is not corrected from the previous comment.

Conflict of interest:

I have no any conflict interest that can influence me to review the manuscript

Over all comment:

1. There are many corrections made on the previous manuscript.

2. Still many grammatical and logical problems

3. sample size calculation, measurement of attitude and interpretation of association are major concerns

Conclusion:

When comparing with the PLOS ONE, research articles publication criteria, I can say about:

• The study presents the results of original research

• Analyses partially not performed to a high technical standard. Example- attitude measurement and Odds ratio interpretation

I recommend to be accepted with minor correction.

Reviewer #3: Tahnk you dear author. It is revelant areas of research.

Although i read and commented the paper during first submission, i were not able to submitt my comments by the time due to lack of access to internate. I observe some modiffication to this submission. Therefore, here are my comments to the current manuscript. Look at the attached PDF file too. I advise you to use a line number to make the review easy.

Title: Capitalize each word except the preposition

Abstract:(1.The introduction requiers editorial 2. The statment "although the family planning services are available in most places, thenational, as well as the regional CPR, is still low, besides, there is an insufficient

distribution of modern contraception and wide range of modern contraceptive choice is

also lacking to meet the demand of clients" is contradictory/Non coherent. 3. CPR should be written full as it appears first time.4. Try to link the problem to your study area. 5. There is spelling erro and capitalization problem to objective. E.g. stud; y is missed and Hamus; H is small letter, Contraceptive, years are missed. 6, Methodology same erros as objective

7. Reult and conclussion section of abstract has also is full of errors.

For comments from introduction to conclussion f the body(see the attached PDF file)

**********

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Reviewer #2: No

Reviewer #3: No

[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.]

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Submitted filename: 2. second reviewed Manuscript Reviewed PONE-D-19-24295_reviewer.pdf

Click here for additional data file.

Submitted filename: PONE-D-19-24295_R2_reviewer comment.pdf

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9 Nov 2019

I corrected all comments accordingly

Submitted filename: last reviwed response.docx

Click here for additional data file.

13 Nov 2019

PONE-D-19-24295R3

Prevalence and determinants of modern contraceptive utilization among Women in the Reproductive Age Group in Edaga-hamus Town, Eastern zone, Tigray Region, Ethiopia, June 2017.

PLOS ONE

Dear Teferi,

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.

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

I would like to thank the authors participated in this research and for the hard work to improve the manuscript.

Overall, the manuscript appears to be improving and you have tried to encompass the feed backs and comments provided by the reviewers. However, still there are issues you need to address at the result and discussion section. For instance, under the subtitle “Knowledge, attitude and utilization” the variables are not vividly stated. You need to depict significant variables that has been used to measure either knowledge or other variables than simply generalizing knowledge or attitude or utilization. Preferably, try to put them as a separate topic at least to address the objectives of your study in a very clear way using appropriate table, graph or chart or texts. But, in this manuscript you have attempted to point out this variables as one that doesn’t give a clear picture at all.

Similarly, the discussion section need further revamp. As I have tried to pin point the flaw of this section on the previous comments, you need to have a clear and evidence based justification for each of your argument. I have noticed some of the statements incorporated unnecessarily, for instance, the capital city of Ethiopia. It is not clear why you want to include this sentences at the middle of the discussion. I couldn’t find a reason why Addis Ababa mentioned as a capital city here. There are similar problems in this section as well.

Please before resubmit the manuscript you need to make necessary changes and read thoroughly the entire manuscript. Consult all the authors involved in this study at the same time read similar published article to improve your paper. Again I would like to inform you that the entire manuscript need aggressive editorial.

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

We would appreciate receiving your revised manuscript by Dec 28 2019 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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Please include the following items when submitting your revised manuscript:

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We look forward to receiving your revised manuscript.

Kind regards,

Solomon Assefa Woreta

Academic Editor

PLOS ONE

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

[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.

21 Nov 2019

i corrected acordingly

Submitted filename: 2 last response to editore.docx

Click here for additional data file.

27 Nov 2019

PONE-D-19-24295R4

Prevalence and determinants of modern contraceptive utilization among Women in the Reproductive Age Group in Edaga-hamus Town, Eastern zone, Tigray Region, Ethiopia, June 2017.

PLOS ONE

Dear Mr Teferi Gebru,

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.

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

Thank you for your time and energy to improve the manuscript. I would like to inform you that your last re-submission exactly the same as the previous submission with no change made on the manuscript. Either wrong document attached or some other reason. Please pay attention to the previous comments that had been given and make necessary changes before re-submission.

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

We would appreciate receiving your revised manuscript by Jan 11 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.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

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'.

A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

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,

Solomon Assefa Woreta

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Thank you for your time and energy to improve the manuscript. I would like to inform you that your last re-submission exactly the same as the previous submission with no change made on the manuscript. Either wrong document attached or some other reason. Please pay attention to the previous comments that had been given and make necessary changes before re-submission.

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

[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.

19 Dec 2019

on time feed back and if you can help me to publish before 2020 it's important for promotion to me.

Submitted filename: 2 last response to editore.docx

Click here for additional data file.

31 Dec 2019

Prevalence and determinants of modern contraceptive utilization among Women in the Reproductive Age Group in Edaga-hamus Town, Eastern zone, Tigray Region, Ethiopia, June 2017.

PONE-D-19-24295R5

Dear Dr. Teferi Gebru,

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.

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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,

Solomon Assefa Woreta

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

11 Feb 2020

PONE-D-19-24295R5

Prevalence and determinants of modern contraceptive utilization among Women in the Reproductive Age Group in Edaga-hamus Town, Eastern zone, Tigray Region, Ethiopia, June 2017.

Dear Dr. Gebremeskel:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. 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.

For any other questions or concerns, please email plosone@plos.org.

Thank you for submitting your work to PLOS ONE.

With kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Solomon Assefa Woreta

Academic Editor

PLOS ONE