Demand for family planning satisfied with modern methods and its associated factors among married women of reproductive age in rural Jordan: A cross-sectional study.

BACKGROUND: A novel indicator, 'percentage of women of reproductive age who are sexually active and who have their demands for FP satisfied with modern contraceptive methods (mDFPS)', was developed in 2012 to accelerate the reduction of unmet needs of family planning (FP). In Jordan, unmet needs for modern contraception remain high. To address this situation, this study measured the mDFPS and identified its associated factors in rural Jordan.
METHODS: This cross-sectional study included married women of reproductive age (15-49 years) from ten villages in Irbid Governorate, Jordan, where advanced health facilities are difficult to reach. A two-stage stratified sampling with random sampling at the household stage was used for this field survey which was conducted between September and October 2016. Univariate analysis was used to assess the differences between mDFPS and unmet mDFPS groups. Logistic regression analysis was performed to identify the correlates of mDFPS.
RESULTS: Of 1019 participants, 762 were identified as needing modern contraception. mDFPS coverage accounted for 54.7%. The most significant factors associated with mDFPS were the husband's agreement on FP (adjusted odds ratio [AOR]: 15.43, 95% confidence interval [CI]: 5.26-45.25), knowledge of modern contraceptives (AOR: 8.76, 95% CI: 5.72-13.40), and lack of awareness of the high risk of conception in the postpartum period (AOR: 2.21, 95% CI: 1.41-3.47). Duration of current residence, receipt of FP counselling at health centres and number of living children were also correlated. In addition, 95.3% of local women were aware of the presence of health centres that were mostly located in a 10-minute walking distance.
CONCLUSION: To increase mDFPS, this study suggested that accelerating male involvement in FP decision-making is necessary through community-based health education. Furthermore, expanding FP services in village health centres and improving the quality of FP counselling in public health facilities are required to correct misconceptions about modern methods among rural women.

Introduction

An estimated 40% of pregnancies were unintended in developing countries in 2012 [1]. It has also been reported that nearly 90% of unintended pregnancies in low- and middle-income countries can be prevented by using modern contraceptive methods [2]. An international consortium, Family Planning 2020 (FP2020), was established in 2012 to accelerate modern contraceptive use to reduce unmet needs of family planning (FP) by 2020 [3], FP2020 developed a novel indicator for one of the FP goals, ‘demand for family planning satisfied with modern methods (mDFPS)’ [4]. mDFPS is defined as the percentage of women (or their partners) who seek to avoid or delay pregnancy but who do not use any modern contraceptive methods [5]. A major difference between mDFPS and the previous contraceptive prevalence rate (CPR) is that this new measure does not consider traditional contraceptive methods.

A few studies have examined mDFPS based on existing data from either demographic health surveys (DHS) or multiple indicator cluster surveys at national level [6, 7]. The studies mostly focused on countries with low CPRs, especially in Sub-Saharan Africa, but rarely focused on Middle Eastern countries. The first comprehensive study on mDFPS was conducted by Westoff in 2012 [6]. He estimated that mDFPS accounted for 47% of women worldwide and illustrated that in general lower education level and lower economic status leads to lower mDFPS coverage. With regard to exposure to information on FP, the study reported that FP messages on television and radio had a positive effect on mDFPS in countries with low CPRs. Another study also found that being younger, poor, having lower education or living in a rural area meant that women tended to have lower mDFPS than the rest of the population [7].

Jordan’s CPR increased from 40% in 1990 to 56% in 2002, and to 61% in 2012; however, the CPR decreased to 52% according to the Jordan Population and Family Health Survey (JPFHS) in 2017–2018 [8, 9]. The Jordanian government explained that one of the major reasons behind this drop was the decline in the use of traditional contraceptive methods. Another reason may be the influx of Syrian refugees, who tended to have lower CPR than Jordanians. However, this information was not clarified because CPR data by nationality was not available in the previous JPFHS in 2012 [8]. JPFHS 2012 estimated that the national average mDFPS in 2012 was 58%, which was not high compared with that of other Middle Eastern countries, including 80% in Egypt, 73% in Morocco and 56% in Turkey [6]. Moreover, Bongaarts and Casterline [10] recently classified Jordan as a pre-fertility-transition country, one of a few such countries outside of Sub-Saharan Africa, and predicted that the country’s high unplanned pregnancy rate and contraceptive failure rate would continue until the mean number of desired children decreased to 3.0 per woman.

This study measured the mDFPS based on field data in rural Jordan and identified factors associated with mDFPS.

Materials and methods

Study setting

This study used the data from a baseline survey conducted by a project funded by the Japan International Cooperation Agency (JICA) in 2016–2018 [11]. The purpose of the project was to strengthen the service delivery function of village health centres (VHCs) in rural villages where advanced health facilities are lacking. Before the project, most VHCs could not provide family planning services. The details of the project design can be found in our study published elsewhere [12]. The study team selected Irbid Governorate as the study site because no similar assistance from other donors had been implemented there before this project. Irbid Governorate is located in northern Jordan, 100 km from the capital Amman, with an estimated population of 1.8 million in 2017 [13]. The study target included currently married women of reproductive age (15–49 years) because only married women are culturally considered as being sexually active in Jordan. Using a structured questionnaire, trained and experienced female researchers conducted face-to-face interviews in Arabic at the individual’s house. Most questions were drawn from JPFHS 2012 [8], and some questions were added from an earlier study in Jordan [14]. Data collection was carried out between September and October 2016.

Sampling

A two-stage stratified sampling was used for the present study. The first stage involved selecting ten villages that had VHCs from four health districts in the Irbid Governorate. The five intervention VHCs were purposely selected by the project team and the Ministry of Health from villages where advanced health facilities are difficult to reach. To match each intervention village, five control villages in the respective health districts were selected by considering similar geographical and socioeconomic characteristics. The second stage involved selecting households by systematic random sampling in each village, using the household frame of the 2015 Jordan Census which was the same as the methodology used in the JPFHS 2012 [8]. The sampling allocation is shown in S1 Table of the Supporting information, and more detailed sampling procedures can be found in our previous study [12]. When a household did not contain a woman eligible for participation, the household was replaced by the nearest one. In case of more than one eligible woman in a household, the researcher randomly selected one participant.

The sample size was calculated based on the following assumptions: 50% CPR detection based on JPFHS 2012 at 95% confidence level (CI) and 80% power. The minimal sample size was then determined to be 384 [12]. In addition, assuming that 80% of the interviewed women have a need for modern contraception, the required sample size was 480 individuals. The original sample size for the purpose of the project of 1000 in total, covered our required sample size [12].

Selected study variables

The essential outcome variable was mDFPS based on the definition of the World Health Organization (WHO) [5]. The numerator for mDFPS was the number of currently married women who were using any modern contraceptive methods in the one month period prior to the survey. Modern methods included pills, condoms (male and female), intrauterine devices, injectables, implants, diaphragms, spermicidal agents (foam/jelly), sterilisation (male and female) [15], and the lactational amenorrhea method (LAM: exclusively breastfeeding within six months after birth), based on the JPFHS definition [8]. The denominator was the total number of women having needs for modern methods among women of reproductive age (15–49 years) who are married or in a union. It included the following:

all fecund women who are using any modern or traditional contraceptives in the last one month;

all pregnant women whose pregnancies were unintended or mistimed at the beginning of the pregnancies;

all postpartum amenorrhoeic women who were not using any contraceptives and whose latest birth was unintended or mistimed; and

all other fecund women who were not using any contraceptives, those who wanted to stop childbearing, those who wished to postpone childbearing for more than two years or those who did not have any plan for childbearing.

Twenty-two independent variables were categorised into four groups: socioeconomic factors; reproduction status; husband-related factors and exposure to reproductive health (RH) information. A variable named ‘knowledge on modern methods’ was regrouped from four options into two options (yes/no): only ‘modern methods are more effective’ was considered ‘yes’, and other options including ‘modern methods are less effective’, ‘modern methods are equally effective’ and ‘don’t know’ were considered ‘no’. Concerning the variable ‘main decision-maker for contraceptive use’, two options (‘husband alone’ and ‘others’) were combined and set as ‘others’ because of the small number of respondents.

Statistical analysis

Firstly, we identified women in need of modern contraception from all respondents. Secondly, univariate analysis was conducted to assess the differences between two groups, mDFPS versus unmet mDFPS, using the chi-square or Fisher’s exact tests. Of the 22 independent variables, nine were selected by univariate analysis because they were statistically significant. Subsequently, two variables in husband-related factors were excluded because one could represent the other two. Finally, seven independent variables with ‘nationality’ as an adjusting variable were entered into multivariate logistic regression analysis (mDFPS versus unmet mDFPS). Statistical significance was set at 0.05. SPSS version 26 (IBM, Chicago, USA) was used for the statistical analysis.

Ethical considerations

Written informed consent was obtained from each participant after full explanation of the study purposes. For married girls aged 15–17 years, in addition to the written consents, verbal consents were obtained from their husbands or mothers-in-law before contacting them. After screening collected data, all data were anonymised. The design and implementation of the study were approved by the Ministry of Interior, Jordan (reference no. 3058/4/2/6; 7 September 2016) and the Ethics Committee of the Faculty of Medicine, Juntendo University, Japan (reference no. 2015104; 29 January 2016).

Results

In total, 1019 women were successfully interviewed. Of these, 762 (74.8%) women had a need for modern contraceptive use according to the WHO definition [5]. The basic characteristics of the respondents are summarised in Table 1. The mean duration of schooling of the women was more than 11 years. The mean number of living children was 3.9, and the gap between the number of desired children and the number of living children was 0.4. Regarding nationality, the majority were Jordanian (95.5%), followed by Syrian (4.2%) and other nationalities (0.3%) (S2 Table). Of all women having a need for modern contraception, 54.7% were currently using modern contraceptive methods, 26.5% were using traditional methods and 18.8% did not use any method. Popular modern methods among the users were IUDs and pills (32.4% and 11.4%, respectively); whereas, the most common traditional method was withdrawal (24.5%) (S3 Table). In terms of accessibility to health facilities, 95.3% of respondents were aware of the nearest public health facility, which was a VHC, and 78.0% have used it in the last year (S4 and S5 Tables). More than 80% of women can access the nearest VHC within 10 minutes mostly on foot (S6 and S7 Tables). Among women who have used VHCs in the last year, services frequently used were a general medical examination by a part-time general practitioner and an immunization program for children. The major reasons for non-use of VHCs were services they needed were not available (S9 Table).

Table 1

Basic characteristics and contraceptive use (n = 762).

	n	Mean	SD
Age (years)	762	35.2	7.6
Schooling (years)	761	11.5	3.0
Age at first marriage (years)	761	20.8	4.1
Age at first delivery (years)	743	22.1	3.8
Number of living children	761	3.9	1.9
Number of desired children	760	4.3	1.4
Monthly household income (Jordan dinar)	734	386.2	182.2
Current contraceptive use (%)
All modern methods	417	54.7
All traditional methods	202	26.5
No use of any methods	143	18.8

The mDFPS coverage accounted for 54.7% (Table 2). Tables 2–5 show the differences between the mDFPS and unmet mDFPS groups. Table 2 describes the socioeconomic characteristics of the two groups. Remarkably, nearly half the women completed secondary education in both groups. One variable (i.e. ‘duration of current residence’) showed statistically significant difference between the two groups; whereas, age, education level, work experience, and household income did not.

Table 2

Socioeconomic characteristics of the two groups: Demand for family planning with modern methods (mDFPS) and unmet mDFPS (n = 762).

	Total n (%)	Unmet mDFPS (%)	mDFPS (%)	p-value
All	762 (100.0)	345 (45.3)	417 (54.7)
Age (years)				0.233
<35	353 (46.3)	168 (48.7)	185 (44.4)
≥35	409 (53.7)	177 (51.3)	232 (55.6)
Schooling (years)				0.097
≤10	212 (27.0)	97 (28.1)	115 (27.6)
11	204 (26.8)	80 (23.2)	124 (29.8)
≥12	345 (45.3)	168 (48.7)	177 (42.5)
Missing	1	0	1
Work experience in the last year				0.438
No	87 (11.4)	36 (10.4)	51 (12.2)
Yes	675 (88.6)	309 (89.6)	366 (87.8)
Duration of current residence (years)				<0.001
≤2	156 (20.5)	92 (26.7)	64 (15.3)
>2	605 (79.5)	252 (73.3)	353 (84.7)
Missing	1	1	0
Monthly household income (Jordan dinars)				0.117
<350	306 (41.7)	148 (44.8)	158 (39.1)
≥350	428 (58.3)	182 (55.2)	246 (69.9)
Missing	28

Table 5

Exposure to reproductive health information of the two groups: Demand for family planning with modern methods (mDFPS) and unmet mDFPS (n = 762).

	Total n (%)	Unmet mDFPS (%)	mDFPS (%)	p-value
Counselling at health centres a				0.001
Yes	214 (28.1)	77 (22.3)	137 (32.9)
No	548 (71.9)	268 (77.7)	280 (67.1)
Counselling at private clinics				0.366
Yes	325 (42.7)	141 (40.9)	184 (44.1)
No	437 (57.3)	204 (59.1)	233 (55.9)
Counselling at non-governmental organisations				0.931
Yes	67 (8.8)	30 (8.7)	37 (8.9)
No	695 (91.2)	315 (91.3)	380 (91.1)
Group lecture in community				0.430
Yes	36 (4.7)	14 (4.1)	22 (5.3)
No	726 (95.3)	331 (95.9)	395 (94.7)
Television				0.885
Yes	517 (67.8)	235 (68.1)	282 (67.6)
No	245 (32.2)	110 (31.9)	135 (32.4)
Printed material				0.209
Yes	191 (25.1)	79 (22.9)	112 (26.9)
No	571 (74.9)	266 (77.1)	305 (73.1)
Internet				0.757
Yes	276 (36.2)	127 (36.8)	149 (35.7)
No	486 (63.8)	218 (63.2)	268 (64.3)
SMS text				0.589
Yes	32 (4.2)	13 (3.8)	19 (4.6)
No	730 (95.8)	332 (96.2)	398 (95.4)
Relative/family				0.292
Yes	170 (22.3)	83 (24.1)	87 (20.9)
No	592 (77.7)	262 (75.9)	330 (79.1)

a Health centres include primary health centres and comprehensive health centres.

Table 3 presents the reproductive status of the two groups. ‘Age at first marriage’, ‘number of living children’, ‘knowledge on modern methods’, and ‘in postpartum amenorrhea’ were significantly different between the mDFPS and unmet mDFPS groups. Conversely, ‘number of desired children’ did not show a significant difference between the two groups. Notably, 15.4% of the participants were experiencing postpartum amenorrhea at the time of survey. We also asked about the reason(s) for non-use of contraceptives to women who were currently not practising FP, and the majority of the reasons were related to temporary infertility and fertility preference (S10 Table). To disclose underlying reasons for non-use of modern contraceptives, we asked a trial question on the perception of modern methods among community people, and the most dominant answer was ‘fear of health problems’ accounting for 84.5% (S11 Table).

Table 3

Reproductive status of the two groups: Demand for family planning with modern methods (mDFPS) and unmet mDFPS (n = 762).

	Total n (%)	Unmet mDFPS (%)	mDFPS (%)	p-value
Age at first marriage				0.032
<20	313 (41.1)	127 (36.9)	186 (44.6)
≥20	448 (58.9)	217 (63.1)	231 (55.4)
Missing	1	1	0
Number of living children				<0.001
0–3	325 (42.7)	175 (50.9)	150 (36.0)
4–5	280 (36.8)	103 (29.9)	177 (42.4)
≥6	156 (20.5)	66 (19.2)	90 (21.6)
Missing	1	1	0
Number of living children				0.500
0–3	159 (20.9)	78 (22.7)	81 (19.4)
4–5	464 (61.1)	203 (59.2)	261 (62.6)
≥6	137 (18.0)	62 (18.1)	75 (18.0)
Missing	2	2	0
Knowledge on modern methods				<0.001
Yes	570 (74.8)	190 (55.1)	380 (91.1)
No	192 (25.2)	155 (44.9)	37 (8.9)
In postpartum amenorrhea				0.002
Yes	117 (15.4)	68 (19.7)	49 (11.8)
No	645 (84.6)	277 (80.3)	368 (88.2)

Husband-related factors are summarised in Table 4. All factors showed statistically significant differences between the two groups. The majority of women (92.9%) perceived that their husbands agreed to contraceptive use; nevertheless, there was a gap of 13.5% between the groups (99.0% for mDFPS and 85.5% for unmet mDFPS). The main decision-makers for contraceptive use among married couples were ‘wife and husband’ jointly (88.6%), whereas, ‘others’ including ‘husband alone’ and ‘parents’, accounted for only 4.2%. Nearly one quarter of the women perceived that their husbands wanted more children than they did.

Table 4

Husband-related factors of the two groups: Demand for family planning with modern methods (mDFPS) and unmet mDFPS (n = 762).

	Total n (%)	Unmet mDFPS (%)	mDFPS (%)	p-value
Husband’s agreement on contraceptive use				<0.001 a
Yes	708 (92.9)	295 (85.5)	413 (99.0)
No	54 (7.1)	50 (14.5)	4 (1.0)
Main decision-maker for contraceptive use				<0.001
Wife and husband	675 (88.6)	291 (84.3)	384 (92.1)
Wife only	55 (7.2)	27 (7.8)	5 (6.7)
Other	32 (4.2)	27 (7.8)	28 (1.2)
Husband’s fertility preference				0.018 a
Same	533 (69.9)	242 (70.1)	291 (69.8)
More than wife	168 (22.0)	68 (19.7)	100 (24.0)
Less than wife	48 (6.3)	24 (7.0)	24 (5.8)
Don’t know	13 (1.7)	11 (3.2)	2 (0.5)

a Fisher’s exact test.

Trends of exposure to RH information by source are listed in Table 5. With respect to person-to-person communication channels (i.e. counselling at health centres, private clinics, and non-government organisations), counselling at private clinics was the most common exposure channel for RH information. Approximately 70% of women reported exposure via television, followed by the Internet. Among RH information channels, only counselling at health centres showed a significant difference between the two groups.

Table 6 shows the result of multivariate logistic regression analysis of factors associated with mDFPS (reference: unmet mDFPS group). Six variables were associated with mDFPS: ‘husband’s agreement on contraceptive use’ (adjusted odds ratio [AOR]: 15.43, 95% CI: 5.26–45.25); ‘knowledge on modern methods’ (AOR: 8.76, 95% CI: 5.72–13.40); ‘in postpartum amenorrhea’ (AOR: 2.21, 95% CI: 1.41–3.47); ‘duration of current residence’ (AOR: 1.83, 95% CI: 1.19–2.83); ‘number of living children’ (AOR: 1.59, 95% CI: 1.12–2.27); and ‘counselling at health centres’ (AOR: 1.66, 95% CI: 1.13–2.44).

Table 6

Factors associated with demand for family planning with modern methods (mDFPS) (n = 759).

	Adjusted Odds Ratio a (95% CI) b	p-value
Age at first marriage (years)
<20	1	0.311
≥20	1.20 (0.84–1.71)
Number of living children
≤3	1	0.010
>3	1.59 (1.12–2.27)
Knowledge on modern methods
Yes	8.76 (5.72–13.40)
No	1	<0.001
Duration of current residence (years)
≤2	1	0.006
>2	1.83 (1.19–2.83)
In postpartum amenorrhea
Yes	1	0.001
No	2.21 (1.41–3.47)
Husband’s agreement on contraceptive use
Yes	15.43 (5.26–45.25)
No	1	<0.001
Counselling at health centres
Yes	1.66 (1.13–2.44)
No	1	0.011

Excluding 1 missing data from ‘age at first marriage’, ‘knowledge on modern methods’, and ‘duration of current residence”.

a Adjusted with nationality.

b CI: confidence interval.

Discussion

This study measured mDFPS coverage in rural Jordan based on data collected from the field. The mDFPS coverage (54.7%) in this study was similar to the estimated mDFPS in rural Jordan in 2017–2018 (53.4%) [9]. Major factors associated with mDFPS in previous studies across the world (i.e. sociodemographic factors) were not detected in the present study [2, 6]. However, the major factors related to unmet mDFPS in our study were similar to widespread factors related to unmet needs for FP reported by past studies, which are discussed individually in the following paragraphs.

The most apparent factor associated with mDFPS in our analysis was the spousal-related factor. Particularly, ‘husband’s agreement on contraceptive use’ was a dominant factor associated with mDFPS. Univariate analysis revealed that the husband’s equal participation in decision-making for FP use and fertility preference also affected mDFPS. Numerous studies on unmet needs for FP have reported that the husband’s fertility preference and his attitude towards FP were crucial factors influencing women’s contraceptive use [16-26]. In Egypt, for example, most users (91.6%) perceived that their husbands agreed on contraceptive use; whereas, approximately only one-fourth of non-users (26.4%) felt that their husbands agreed [17]. Many studies suggested that FP programmes must mobilise husbands and other influential male members in families and communities, as a whole, in order to address the negative social norms or barriers towards use of modern methods in rural settings [19, 21, 25, 27, 28]. Nevertheless, most of these studies, including our study, relied on data by asking about women’s perceptions of their husbands’ acceptance of FP use. Casterline et al. [18] suggested that there were considerable discrepancies between the wife’s perceptions of her husband’s FP acceptance and his actual acceptance. In-depth research of both sexes of the couples could investigate the real preferences and attitudes towards modern methods in rural Jordan.

The other important factor was accurate knowledge of the effectiveness of modern contraceptives. Women who perceived the effectiveness of modern methods were nearly nine times more likely to use modern contraceptives than those in the other group. The latest review studies identified that remaining obstacles to non-use of contraception in countries with an increase the CPR and rising education levels were fears of side-effects, adverse health risks, and the risk of infertility [25, 29–32]. Although we asked women who were currently not practising FP for their reason(s) for non-use of contraceptives, no insightful results appeared (S10 Table). On the contrary, in response to our question on the reasons for non-use of modern methods among people in the community, ‘fear of health problems’ was the most dominant reason (S11 Table). This indicated that a vague sense of fear of health effects may be the underlying reason for non-use of modern methods in rural Jordan. A prior study in Jordan also reported that a latent fear of health risks associated with hormonal contraceptive methods and IUDs might have turned into a perception of modern methods being ineffective [14]. These findings implied that the rural population in Jordan fears potential side-effects and adverse health effects as well as the risk of infertility. Campbell et al. [33] urged that misinformation may be the real barrier to using modern methods. Overall, our analysis suggested that adequate education regarding modern methods should be enhanced by providing high-quality person-to-person counselling at public health centres in rural Jordan to remove all misperceptions of modern methods by providing high-quality person-to-person counselling at public health centres in rural Jordan [31, 34, 35].

This study also revealed that a low perception of risk of getting pregnant during the postpartum period affected mDFPS. Women experiencing postpartum amenorrhea were more than twice as likely to have unmet mDFPS than were the other group. Previous studies pointed out that many women were not aware of the high risk of pregnancy during the postpartum period [26, 30, 31, 36]. A study from the state of Virginia in the USA reported that mothers who attended their postpartum care visit were 1.44 times more likely to start FP in the postpartum period than those who did not attend [37]. In 2016, the Jordanian Ministry of Health introduced a new regulation to the effect that mothers who do not practice LAM should start contraception after 21 days of delivery to avoid unintended pregnancies [38]. Our results, however, showed that this regulation had not yet reached rural communities at the time of the survey. Because integrating FP counselling into antenatal/postnatal care is effective [2, 21], the ministry needs to facilitate the provision of FP counselling during antenatal/postpartum care visits at health facilities and provide appropriate contraceptives to mothers with contraceptive needs at postnatal visits as a part of the continuum of care for maternal and child health [2, 20, 21].

We found that local women were aware of and could easily access VHCs in rural Jordan. Meanwhile, comprehensive or primary health centres were the most popular places where modern methods could be obtained (S12 Table). This implies that the VHC services were limited and did not meet women’s needs, especially with regards to FP services. In terms of information on RH only counselling at public health centres had a positive influence on mDFPS. Counselling at private clinics was not associated with mDFPS, even though the exposure rate was higher (42.7%) than that of health centres (28.1%) (Table 5). Earlier studies in Jordan reported that women, especially those in urban areas, depended highly on private clinics for modern contraception [27, 39, 40]. Campbell et al. [33] determined a close correlation between travel time to a health facility and women’s use of contraceptives. Overall, our findings highlighted the important role of public health centres to increase mDFPS coverage among married women in rural Jordan. In this respect, expanding FP services at VHCs, and increasing people’s awareness of the usefulness and safety of modern contraceptives may be a key strategy for accelerating mDFPS in rural Jordan.

Our analysis showed that women living in the current community for more than two years were 1.83 times more likely to have their demands for modern methods met than women living in the current community for a shorter period. Earlier studies in Kenya and Zambia presented that migrant women in rural areas did not show significant effects on using modern methods compared with non-migrant women in rural areas [41, 42]. Our result, however, may be interpreted as meaning that longer residence generates a competency to access available health resources in communities, subsequently leading to use of their services.

With respect to the migrant issue, we originally considered Syrian refugees and other displaced populations in Jordan; however, only few Syrians and other nationalities were living in our study areas. It was because 83% of Syrian refugees in Jordan live in urban areas [43] where they can easily access refugee services with less travel cost and obtain necessary information in a close-knit community. Further studies are required to explore the Syrian refugees’ situations in terms of RH and to establish a resilient health system for all.

In our analysis, the number of living children was also associated with mDFPS, in line with the results of earlier studies [22, 44]. Women with four or more children were more likely (1.59 times) to use modern contraceptive methods than those with fewer than four children. This may be explained by the stronger motivation to avoid pregnancies after reaching the desired number of children. Conversely, there was no association between the number of desired children and mDFPS. Many studies reported that women’s preferences on childbearing in terms of numbers and timing were ambivalent and their desired number of children was changing over their lifetime [22, 23, 35]. Additionally, mothers may hesitate to respond with a number smaller than their actual number of living children or they may accept an unplanned pregnancy after the birth of the child [22, 23, 26, 35]. To examine these phenomena, further psychological approaches are required.

The strength of this study (to the best of our knowledge) was that it is the first community-based study in Jordan on mDFPS with adequate power to identify the mDFPS coverage. However, there are several limitations. The most significant limitation of this study may be possibility of containing biases from self-reporting by local women, such as practicing either modern or traditional contraception, fertility preferences, or the wantedness of recent births/pregnancies. Some bias may have been included; therefore, mDFPs may have been underestimated [35]. Secondly, this study was conducted only in the Irbid Governorate and could not represent the whole of Jordan. In addition, considering the current situation in Jordan, the influence of Syrian refugees cannot be ignored; however, our study could not examine this aspect due to the small sample size. Thirdly, as mentioned earlier, using women’s perceptions of husband’s preference generates some unreliability of reality because of discrepancies between the parties. Fourthly, owing to our limited sample size, this study did not determine the factors related to birth spacing and birth limitation, which are important parameters for identifying further needs regarding mDFPS [25, 26]. Nevertheless, our study began to reveal the current status of mDFPS in evidence and suggested the need for further strengthening of FP programmes in rural Jordan.

Conclusion

The current mDFPS coverage was still almost half in rural Jordan. Our analysis highlighted that significant factors associated with mDFPS were spousal agreement for FP use, awareness of the effectiveness and safety of modern contraceptives, and lack of risk of conception during the postpartum period. To increase mDFPS, our results suggested accelerating male involvement in FP decision-making is necessary through community-based health education. Furthermore, expanding FP services at VHCs and improving FP counselling in all primary health facilities, with a special focus on allaying the fear of adverse health effects from modern methods and increasing awareness on the importance of postpartum contraception are required.

Number of samples by village.

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Participants according to nationality.

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Contraceptive methods among women having needs for modern contraception.

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Awareness of the nearest village health centres.

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Use of village health centre in the last year.

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Transportation mean to the nearest village health centre.

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Time required to reach the nearest village health centre.

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Services used at village health centre.

(DOCX)

Click here for additional data file.

Reasons for non-use of village health centre.

(DOCX)

Click here for additional data file.

Reasons for non-use of family planning.

(DOCX)

Click here for additional data file.

Perceived reasons for non-use of modern contraceptives in community.

(DOCX)

Click here for additional data file.

Places for obtaining contraceptives among women currently using family planning.

(DOCX)

Click here for additional data file.

24 Oct 2019

PONE-D-19-25354

Demand for family planning satisfied with modern methods and its determinants among married women of reproductive age in rural Jordan: A community-based cross-sectional study

PLOS ONE

Dear Makiko Komasawa,

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.

The first reviewer has made several comments that will help guide the process.

We would appreciate receiving your revised manuscript by 23rd November 2019. 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,

Mary Hamer Hodges

Academic Editor

PLOS ONE

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

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3. Thank you for stating the following financial disclosure:

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a) Please provide an amended Funding Statement that declares *all* the funding or sources of support received during this specific study (whether external or internal to your organization) as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now.

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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: 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: No

Reviewer #2: No

**********

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

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

Reviewer #1: No

Reviewer #2: Yes

**********

5. Review Comments to the Author

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

Reviewer #1: This manuscript presents results from a cross-sectional survey assessing prevalence and correlates of modern contraceptive method use among married women in Irbid governorate. While some of the findings are noteworthy for adjusting program and counseling approaches to optimize modern method use, there are some concerns with the methodological approaches. A major revision is needed with better justification for and acknowledgment of bias associated including women who report recent undesired or mistimed pregnancy during or after said pregnancy, whether LAM was included as a modern method, and more thoughtful consideration of some of the findings. Overall the manuscript would benefit from review by a native English speaker or professional editor as there are numerous examples of awkward phrasing.

Abstract:

• The abstract gives the impression that mDFPS was developed solely for Jordan. Suggest reversing the order this is mentioned with the statement regarding Jordan’s rates of unmet FP need.

• The word “determinants” is inappropriate for a cross-sectional study as no causality may be attributed between the variable and the use or non-use of modern methods. Please use the word “correlates”.

• In the Methods, please define if the sample was a probabilistic (was mapping and random selection used?) or a convenience sample. Was this a household level sample or was enrollment conducted elsewhere?

• In the Conclusions section, I am concerned that improving counseling quality at public health centers is seen as the solution to increasing modern contraceptive use. After reading the Methods section within the manuscript, the household sample (which needs to be mentioned in this abstract) likely included women who are not able to access health services, potentially due to being displaced or to gender-based social norms that reduce women’s agency in accessing health care. Changing the quality of counseling at public facilities will not solve access problems but creates a more compelling reason for male engagement and also needs to consider that recently displaced populations likely don’t know where to access health care or may not have access to national public systems as non-citizens (either perceived or actual). The significant association of greater odds of using a modern method with residing in the area for more than two years argues that displaced populations may face barriers to accessing facilities in Jordan and thus cannot access modern methods or related counseling.

Introduction:

• The Introduction is generally well-written but would benefit from some alternative hypotheses for why CPR has fallen in Jordan. It is correct that mDFPS would be lower than CPR with removal of traditional methods but the dynamic population shifts in Jordan due to conflict in Iraq and Syria bear consideration that new population groups with different norms surrounding reproductive decisions should be considered.

Methods:

• Please provide further information about the setting – why was Irbid Governorate chosen? Is CPR there lower than the rest of the country? Have there been dynamic populations shifts? Please provide greater context.

• Please provide greater detail as to how the districts were chosen – this appears to be purposive sampling based on ability to access health services. Is this correct? Was the second sampling stage inclusive of community mapping to ensure a random sample?

• While other papers using mDFPS have included pregnant women reporting mistimed or unwanted pregnancies as women with contraceptive need, including this group may lead to substantive reporting bias, particularly for women who have already delivered and are amenorrheic as they would be likely to under-report that the pregnancy was unwanted or mistimed with a new infant. This is particularly as this variable was associated with modern method use.

• Regarding the postpartum group, was Lactational Amenorrhea Method queried and included with modern method use? As this group comprised a relatively large portion of surveyed women, it is important to know whether this group was included in mDFPS users if they cited LAM as their method.

• Please describe how missing data were handled in analysis.

Results:

• In the Tables, please remove the asterisks since the p-values are reported.

• Exposure to RH information by source appears to be in proportions, not by mean. Please revise the description.

Discussion:

• Earlier comments regarding query about LAM and its inclusion as a method for amenorrheic postpartum women (were these women asked if they were exclusively breastfeeding?), relying on report for whether pregnancies were unintended or mistimed, and whether women are able to access facilities vs. recommending improving counseling at facilities should be used to edit this section accordingly.

• The limitations section is fairly sparse and should first and foremost mention that all data was by participant report and is subject to recall and disclosure bias, which may be higher given the sensitivity of the topic.

• There is very little mention of length of residence in the area and possible association with refugee communities that have different norms around FP use. This information should feature prominently in this paper.

• Lines 251-253 need references to support the statement.

• The text in lines 274-277 needs to be clarified.

• The information on perceived reasons for not using contraceptives among women in their community belongs in the Results section – please do not introduce data for the first time in the Discussion section.

• Please see comments in the Abstract conclusion section to revise the Conclusion section here.

Reviewer #2: This cross sectional study aimed to assess demand for family planning satisfied with modern methods and its determinants among married women of reproductive age in rural Jordan. In general it is straightforward analysis of data and perhaps might be interesting by those who have close interest on the topic.

The only comment to imporve the paper is to better describe who are unmet mDFPS? At present inadequate information are presented.

**********

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: Yes: Catherine S. Todd

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.

11 Dec 2019

Please kindly refer the Response to Reviewers and Response to Editors files.

Submitted filename: Response to Editors_Dec11.docx

Click here for additional data file.

7 Jan 2020

PONE-D-19-25354R1

Demand for family planning satisfied with modern methods and its associated factors among married women of reproductive age in rural Jordan: A cross-sectional study

PLOS ONE

Dear Makiko Komasawa,

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 6th February 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,

Mary Hamer Hodges

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

We recommend a general review of the presentation by a native English speaker familiar with the subject.

[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: No

Reviewer #2: No

**********

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

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: This revised manuscript has largely addressed prior critiques but would still benefit from some final polishing and clarification before acceptance. The manuscript also need further review by a native English speaker as there are several areas with subject-verb disagreement and other grammatical errors or awkward phrasing.

Abstract:

• As an example of awkward phrasing and need for editing, the sentence, “A filed survey, through two-stage stratified sampling of village and household levels and systematic random sampling for households, was conducted from September to October 2016.” would benefit from being revised to “Two-stage stratified sampling with random sampling at household stage was used for this field survey conducted between September and October 2016.”

• In the Results, the statement “In addition, local women were aware of and easily access public health centres in their areas.” needs proportions to put the data into perspective for this sample.

Introduction:

• Though the authors mention that a professional editor reviewed this revised manuscript, there are still multiple misspellings, issues with subject-verb agreement, and awkward phrasing (example: “”

• The statement,”Generally, low education level and low economic status cause lower mDFPS coverage” needs to be revised and referenced as low education and economic status are not causal factors of low modern FP use but are correlates.

Methods:

• This section has markedly improved. However, please capitalize proper nouns like Irbid Governorate and discuss the setting in present verb tense (current phrasing states “Irbid governorate was located in northern Jordan” – isn’t Irbid Governorate still located in northern Jordan?).

• Please add detail to specify whether households were mapped to enable random selection and what was done if a selected household did not contain an eligible woman for participation. While an earlier manuscript is referenced, it would be helpful to readers here to be able to see in the text that this is truly a probabilistic sample.

Results:

• No comments.

Discussion:

• The Limitations section still needs attention. The dependent variable, whether a woman was using a method, relies on participant report and this needs to be acknowledged as a limitation.

Reviewer #2: This is the second time that I review this manuscript. I feel the manuscript improved greatly. My comment is attended. No further comments.

**********

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: Yes: Catherine Todd

Reviewer #2: Yes: Prof. Ali Montazeri

[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.

25 Jan 2020

Please kindly fine the response letter dated on Jan.25

Submitted filename: Response to Reviewers_Jan25.docx

Click here for additional data file.

31 Jan 2020

PONE-D-19-25354R2

Demand for family planning satisfied with modern methods and its associated factors among married women of reproductive age in rural Jordan: A cross-sectional study

PLOS ONE

Dear Makiko Komasaw,

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.

Ar recommended please review carefully to ensure the language properly reflects the findings as identified by the reviewer.  This would be best performed in consultation with a native English speaker.

We would appreciate receiving your revised manuscript by 15th February. 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,

Mary Hamer Hodges

Academic Editor

PLOS ONE

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (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 #1: Yes

**********

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

Reviewer #1: 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

**********

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

**********

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: The authors have responded to all comments. However, the response may have been done in haste as there are still seeming inaccuracies that should be remedied by careful review. For example, the correction regarding Westoff et al.'s findings regarding modern contraceptive method prevalence and "that in general mDFPS is negatively associated with wealth and education." Shouldn't this be positively associated as women from higher wealth quintiles and with higher education levels are MORE likely to use modern FP methods? While the manuscript is essentially acceptable, I would urge the authors to again carefully review their text for accuracy prior to copy-editing.

**********

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: Yes: Catherine Todd

[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.

1 Feb 2020

Please kindly find the file named "Response to Reviewers" dated on Feb 2.

Submitted filename: Response to Reviewers_Feb2.docx

Click here for additional data file.

20 Feb 2020

PONE-D-19-25354R3

Demand for family planning satisfied with modern methods and its associated factors among married women of reproductive age in rural Jordan: A cross-sectional study

PLOS ONE

Dear Makiko Komasawa,

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 29th February 2020. 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,

Mary Hamer Hodges

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

There has been a marked improvement and is eaier to read and understand. However between the orginal version and R1 there has been a change of p value in Table 2 for age: previously reported as 0.012 and now reported as 0.233. However, the narrative is still saying 'Two variables (i.e. age and duration of current residence) showed statistically significant differences between the two groups, whereas years of schooling, work experience, and household income did not.

Please reconfirm the p value for age or adjust the narrative.

Spacing in Tables 3, and 6 after the symbol for less than or more than should be deleted.

Please harmonize decimal places for were then 1.8 times compared to (1.60 times)

[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.

22 Feb 2020

Please kindly find the file named "Response to reviewers" dated on Feb 22.

Submitted filename: Response to Reviewers_Feb22.docx

Click here for additional data file.

2 Mar 2020

Demand for family planning satisfied with modern methods and its associated factors among married women of reproductive age in rural Jordan: A cross-sectional study

PONE-D-19-25354R4

Dear Dr.Makiko Komasawa,

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.

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Thank you for these changes

Reviewers' comments:

5 Mar 2020

PONE-D-19-25354R4

Demand for family planning satisfied with modern methods and its associated factors among married women of reproductive age in rural Jordan: A cross-sectional study

Dear Dr. Komasawa:

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