Factors associated with modern contraceptive use among men in Pakistan: Evidence from Pakistan demographic and health survey 2017-18.

OBJECTIVE: The role of men in family planning is critical in patriarchal societies like Pakistan. The objective of this study is to explore the predictors of modern contraceptive use among Pakistani men.
METHODS: This study is a secondary analysis of Pakistan demographic and health survey (PDHS) 2017-18 data. The study sample consists of 3691 ever married men aged 15-49 years. Pearson's chi square test and logistic regression were used to find out the determinants of modern contraceptive use among men. Data analysis was carried out in December, 2020.
RESULTS: Findings of logistic regression showed that men who were uneducated (aOR = 0.746; 95% CI = 0.568-0.980), residing in Sindh (aOR = 0.748; 95% CI = 0.568-0.985), Baluchistan (aOR = 0.421; 95% CI = 0.280-0.632) or FATA (aOR 0.313; 95% CI 0.176-0.556) and those who belonged to the poorest wealth quintile (aOR = 0.569; 95% CI = 0.382-0.846) were less likely to use modern contraceptives. Men who did not wish for another child (aOR = 2.821; 95% CI = 2.305-3.451) had a higher likelihood of modern contraceptive use. Finally, men who thought that contraception was women's business (aOR = 0.670; 95% CI = 0.526-0.853) and those who did not discuss family planning with health worker (aOR = 0.715; 95% CI = 0.559-0.914) were also less likely to use modern contraceptives.
CONCLUSION: Reproductive health education of males, targeting males, in addition to, females for addressing family planning issues and improvement of family planning facilities in socioeconomically under-privileged regions are suggested to improve contraceptive use among couples.

Introduction

Contraception plays a pivotal role in the improvement of sexual and reproductive health. It also serves to reduce maternal deaths resulting from unsafe abortions and unwanted pregnancies [1]. A significant association has been observed between fertility reduction and decrease in infant, child and maternal mortality [2]. It was observed that about 13% of infant deaths, 25% of under-five mortalities, and 35% of maternal deaths could be prevented by increasing birth interval by three years [3].

Comparing the Data from Pakistan demographic and health survey (PDHS) conducted in 2017–18 to that of PDHS 2012–13, it becomes evident that the use of modern contraceptives did not improve during this period (35% in PDHS 2012–13 and 34% in PDHS 2017–18) [4]. The contraceptive prevalence rate in Bangladesh (2014) and India (2015) is 62.4% and 52.4% respectively [5, 6].

Pakistan is situated in south Asia and is among the top ten most populous countries in the world. Population growth rate of Pakistan is 2% [7]. Government of Pakistan has taken several measures to reduce population growth rate. Among these measures, improvement in family planning services is worth mentioning. The annual expenditure of family planning services is about US $55 per woman [8]. Despite these efforts the uptake of contraceptives by couples remains low in Pakistan. The unmet need of family planning reported in PDHS 2017–18 was 17% which is less than that reported in PDHS 2012–13 (20%) [4].

Various factors like socioeconomic status, education, cultural beliefs, area of residence, religion and wrong perceptions about family planning determine the utilization of modern contraception [9]. In agriculture based societies, men usually wish to have large number of children because they serve as a source of livelihood. This perception of men creates hinderance in the utilization of contraceptives by couples [10-12]. Studies have also reported that educated parents can better perceive the benefits of having fewer children. In addition, better contraceptives uptake in urban areas may be accounted for by the availability of better health care services and access to information [13]. A study conducted in Karachi reported various myths and beliefs that may lead to reduced contraceptive uptake by couples. These included, perceived adverse effects of contraceptives like weight gain, birth defects, infertility and reduced sexual pleasure. Furthermore, cultural disapproval and perception that practicing contraception leads to displeasure of God were found to be prevalent [14].Decisions about the number of children are largely dependent on males in patriarchal societies like Pakistan [15, 16]. International conference on population and development held in Cairo (1994) highlighted the importance of involving males in the issues of reproductive and sexual health. Despite this, participation of males in family planning issues remains limited [17, 18].

Pakistan also participated in the international conference on population and development (ICPD) held in Nairobi. During this summit, Pakistan committed to achieve universal sexual and reproductive health coverage, increase contraceptive prevalence rate to 60% by 2030, finance ICPD programs and to eliminate gender based violence. However, Engagement of males in family planning programs was not specifically targeted [19]. Research studies exploring the predictors of contraceptive use among couples have overlooked the role of men [20]. This indirectly endorses the concept that contraception is the responsibility of females [21, 22]. Because of a generalized perception that contraception is women’s affair, men have remained excluded from family planning matters [23].

This study attempts to explore the factors determining the use of modern contraceptive methods among Pakistani men using PDHS 2017–18 dataset. The results of this analysis will be significant not only for the Government of Pakistan but also for various non-government organizations that are working to promote family planning. In addition, this paper also puts emphasis on the fact that the objectives of family planning programs may not be accomplished without considering the role of men as decision makers in the matters of family planning and reproductive health in patriarchal societies.

Methods

Data source

This study is a secondary analysis of Pakistan Demographic and Health Survey (PDHS) 2017–18. PDHS is a cross sectional survey that reports health and demographic features of Pakistani population. The survey was conducted by national institute of population studies (NIPS), Pakistan. Data collection during the survey was done as follows. Eight regions viz Punjab, Sindh, Khyber Pakhtunkhwa, Baluchistan, Azad Jammu and Kashmir, Gilgit Baltistan, Islamabad and Federally Administered Tribal Areas (FATA) were surveyed. Each region was divided into urban and rural areas creating sixteen strata. This was followed by the selection of clusters from each stratum using probability sampling. A total of 580 clusters were selected. Nineteen of them were abandoned due to security risk. The final number of clusters became 561. Selection of clusters was followed by the sampling of households from each cluster. Systematic random sampling was used for this purpose. A fixed number of twenty-eight households were selected from each cluster. Eventually, 16,240 households were surveyed.

This survey used six questionnaires namely household questionnaire, women’s questionnaire, men’s questionnaire, fieldworker’s questionnaire, biomarker questionnaire and community questionnaire. Men’s questionnaire was used to interview ever married men aged 15–49 years. A total of 3691 ever married men aged 15–49 years across Pakistan (including Azad Jammu Kashmir and Gilgit Baltistan) were interviewed in this survey. This secondary analysis was carried out using the data of 3691 ever married men aged 15–49 years in December, 2020.

Ethical approval for PDHS 2017–18 was obtained from the National Bioethics Committee, Pakistan Health Research Council and the International Review Board of ICF. For more details on PDHS sample collection procedure, please refer to the PDHS 2017–18 report [4]. Owing to secondary nature of this analysis, no informed consent or ethical approval was needed. However, permission to use the data for this study was acquired from ICF International after providing a brief description of the study.

Dependent variable

The outcome variable is “modern contraceptive usage”. It is a binary variable with two categories encoded as ‘0’ (men who reported no modern contraceptive use) and ‘1’ (men who reported the use of modern contraceptive methods by themselves or their female partners). Contraceptive methods categorized as ‘modern’ in PDHS include pills, injections, intrauterine devices, implants, male/female condoms, diaphragms, foam, jellies, female/male sterilization, emergency contraception and lactational amenorrhea. Contraceptive methods categorized as ‘traditional’ include withdrawal, periodic abstinence and abstinence. The third category of contraceptive methods described in PDHS is ‘folkloric methods’ which are country specific.

Independent variables

Explanatory variables selected for this study belonged to four different categories including sociodemographic factors, socioeconomic factors, behavioral factors and communication with health system. Fig 1 demonstrates a conceptual framework of the variables used in this study. Demographic factors were Age, region (Punjab, Sindh, Khyber Pakhtunkhwa, Baluchistan, Islamabad, Gilgit Baltistan, Azad Jammu Kashmir and FATA) and residence (urban/rural). Socioeconomic variables selected for the study were education, household wealth index and employment status (obtained from the question if the respondent was currently working). Behavioral factors included fertility preference (wish for additional children/ no wish for more children/ sterilized or partner-less) and belief in certain false notions like “Contraception is women’s business” and “women who use contraception become promiscuous.” Communication with health system was assessed by asking the respondents if they discussed family planning with a health worker.

Fig 1

Schematic representation of study variables.

The variables “age” and “education were recoded. Age was divided into three categories; 15–29 years, 30–45 years and 45 or above. Education level was divided into three categories: no education, primary education, secondary education or higher. Wealth index (poorest/poorer/middle/richer/richest) was calculated during the survey by using data on household assets (e.g. type of vehicle owned, possession of various electronic appliances et c.) and other household characteristics (e.g. building material of the house etc.).

Statistical analysis

Data analysis was performed using IBM SPSS version 21. The data was weighted using men’s sample weights in PDHS dataset. Descriptive statistics were applied to obtain a summary of background characteristics of the respondents. Initially, Pearson’s chi squared test was used to determine the relationship between modern contraceptive use and each predictor variable. All the independent variables, except employment status (Currently working or not), were significantly associated with the outcome and were selected for multivariable logistic regression. Before running logistic regression, all the covariates were analyzed for the presence of multicollinearity using tolerance statistics and variance inflation factor “S1 Table”. No evidence of multicollinearity was detected. Bivariable logistic regression was run first. Finally, multivariate binary logistic regression was used by adjusting for the covariates to determine the impact of predictor variables on modern contraceptives use among Pakistani men. A p value of less than 0.05 was considered statistically significant.

The choice of reference category in logistic regression was guided by relevant literature. In addition, the reference categories were selected based on the hypothesis e.g. “residents of Punjab” and “educated men” were anticipated to have a higher modern contraception uptake. Thus, these were selected as reference categories to check how these categories differ relative to their counterparts.

Results

Background characteristics of the respondents

The findings of descriptive statistics are presented in Table 1. The respondents included in the analysis were 3691 ever married men age 15–49 years. Only about 19.3% individuals reported that they were using a modern contraceptive method. Nearly half (49%) of men were residing in rural areas. About a quarter (23.1%) of men belonged to the province Punjab while the proportion of respondents from Sindh, KPK and Baluchistan was 21.1%, 13.7% and 14.1% respectively. The level of education of more than half (59.4%) of men was secondary or higher. Less than one fourth (23.5%) of the respondents received no education. Each wealth quintile had an approximately similar number of respondents. Only 5.2% of the men had no employment (not currently working). More than half (59.5%) of the individuals responded that they wanted to have another child. About one third (33.7%) of the men said that they no more wished for another child. Only 12.4% men discussed family planning with a health care worker within a few months preceding the survey. About one quarter of men (25.1%) agreed to the notion that contraception was women’s business. About 1 in every ten men (9.9%) believed that using contraception could make women promiscuous.

Table 1

Demographic, socioeconomic and behavioral characteristics of men.

Variables		Percentage	Frequency
Age	15–29	27.5	1014
	30–44	56.4	2081
	45 and above	16.1	596
Residence	Urban	51.0	1884
	Rural	49.0	1807
Region	Punjab	23.1	853
	Sindh	21.1	778
	KPK	13.7	505
	Baluchistan	14.1	522
	Islamabad	7.2	265
	Gilgit Baltistan	5.7	210
	Azad Jammu Kashmir	9.1	336
	FATA	6.0	222
Education	None	23.5	869
	Primary	17.0	628
	Secondary or higher	59.4	2194
Wealth index	Poorest	18.2	672
	Poorer	21.7	801
	Middle	19.2	708
	Richer	19.6	725
	Richest	21.3	785
Currently working	Yes	94.8	3496
	No	5.2	191
Fertility preference	Have another	59.5	2154
	No more	33.7	1221
	Undecided	4.7	168
	Sterilized/infertile/no partner	2.1	76
Discussed family planning with health worker	Yes	87.6	459
	No	12.4	3231
Contraception is woman’s business	Agree	25.1	928
	Disagree	65.7	2426
	Don’t know	9.1	336
Women who use contraception become promiscuous	Agree	9.9	365
	Disagree	76.4	2818
	Don’t know	13.7	506
Modern contraception usage	Yes	19.3	714
	No	80.6	2977
Total		100.0	3691

Table 2 presents the findings of Pearson’s Chi square test. Age, region, residence, education, wealth index, fertility preference, discussion with health worker and the behavioral factors (belief in the notions “contraception is women’s business” and “women using contraception become promiscuous”) were significantly associated with modern contraceptive usage (p<0.001). The variable ‘currently working’ did not have a significant relation with the usage of modern contraceptive methods.

Table 2

Association of independent variables with modern contraceptive use.

Variables		Modern contraceptive use (%)		P value
		No	Yes
Age	15–29	87.2	12.8	0.001
	30–44	78.4	21.6
	45 and above	75.4	24.6
Residence	Urban	77.5	22.5	0.001
	Rural	83.3	16.7
Region	Punjab	75.8	24.2	0.001
	Sindh	83.5	16.5
	KPK	75.4	24.6
	Baluchistan	92.6	7.4
	Islamabad	70.5	29.5
	Gilgit Baltistan	73.3	26.7
	Azad Jammu Kashmir	75.8	24.2
	FATA	93.2	6.8
Education	None	87.8	12.2	0.001
	Primary	79.1	20.9
	Secondary or higher	77.7	22.3
Wealth index	Poorest	90.6	9.4	0.001
	Poorer	83.5	16.5
	Middle	77.8	22.2
	Richer	75.8	24.2
	Richest	74.6	25.4
Currently working	Yes	80.1	19.9	0.255
	No	83.7	16.3
Fertility preference	Have another	87.4	12.6	0.001
	No more	69.8	30.2
	Undecided	84.0	16.0
	Sterilized/infertile/no partner	39.5	60.5
Discussed family planning with health worker	Yes	72.4	27.6	0.001
	No	81.5	18.5
Contraception is woman’s business	Agree	85.4	14.6	0.001
	Disagree	76.8	23.2
	Don’t know	91.8	8.2
Women who use contraception become promiscuous	Agree	80.8	19.2	0.001
	Disagree	79.0	21.0
	Don’t know	87.0	13.0

Determinants of modern contraceptive use

Table 3 presents the findings of logistic regression. The odds of modern contraception usage was significantly low in the residents of Sindh (aOR = 0.748; 95%; CI = 0.568–0.985), Baluchistan (aOR = 0.421; 95% CI = 0.280–0.632) and FATA (aOR = 0.313; 95% CI = 0.176–0.556) as compared to those of Punjab. The respondents who received no education had lesser odds (aOR = 0.746; 95% CI = 0.568–0.980) of using modern contraceptive methods when compared to those with primary, secondary or higher level of education. The odds of modern contraceptive usage in men belonging to the poorest wealth quintile (aOR = 0.569; 95% CI = 0.382–0.846) were significantly less relative to other wealth quintiles. Higher odds of modern contraceptive usage were found in those men who showed no desire to have another child (aOR = 2.821; 95% CI = 2.305–3.451). Those respondents who had no discussion related to family planning with a health worker were significantly less likely (aOR = 0.715; 95% CI = 0.559–0.914) to use modern contraceptive methods. Finally, the men who agreed (aOR = 0.670; 95% CI = 0.526–0.853) to the concept that contraception was women’s business had significantly lesser odds of using modern contraceptive methods. In addition, the men who were reportedly sterilized, infertile or currently partner-less had higher odds (aOR = 11.224; 95% CI = 6.706–18.784) of modern contraceptive usage compared to those who wanted more children.

Table 3

Predictors of Modern contraceptive use among men.

Variables		Modern contraceptive use
		Bivariate logistic regression			Multivariate logistic regression
		OR	95% CI	P value	aOR	95% CI	P value
Age	15–29	1.00			1.00
	30–44	1.89	1.52–2.34	0.001	1.22	0.96–1.55	0.091
	45 and above	2.23	1.71–2.91	0.001	1.00	0.73–1.36	0.998
Residence	Urban	1.00			1.00
	Rural	0.69	0.58–0.81	0.001	0.87	0.71–1.07	0.202
Region	Punjab	1.00			1.00
	Sindh	0.61	0.48–0.78	0.001	0.74	0.56–0.98	0.039
	KPK	1.01	0.78–1.31	0.900	1.26	0.95–1.68	0.101
	Baluchistan	0.24	0.17–0.36	0.001	0.42	0.28–0.63	0.001
	Islamabad	1.30	0.95–1.79	0.092	1.19	0.84–1.68	0.323
	Gilgit Baltistan	1.13	0.80–1.60	0.468	1.44	0.98–2.13	0.060
	Azad Jammu Kashmir	0.99	0.73–1.34	0.975	1.01	0.73–1.40	0.933
	FATA	0.22	0.13–0.39	0.001	0.31	0.17–0.55	0.001
Education	None	0.48	0.38–0.81	0.001	0.74	0.56–0.98	0.035
	Primary	0.92	0.74–1.15	0.486	1.10	0.86–1.41	0.430
	Secondary or higher	1.00			1.00
Wealth quintile	Poorest	0.30	0.22–0.41	0.001	0.56	0.38–0.84	0.005
	Poorer	0.58	0.45–0.74	0.001	0.88	0.94–1.20	0.421
	Middle	0.84	0.66–1.06	0.157	1.06	0.80–1.39	0.681
	Richer	0.93	0.74–1.18	0.593	1.09	0.85–1.41	0.466
	Richest	1.00			1.00
Fertility preference	Have another	1.00			1.00
	No more	0.12	0.06–0.23	0.001	2.82	2.30–3.45	0.001
	Undecided	0.09	0.05–0.15	0.001	1.42	0.90–2.25	0.125
	Sterilized/infertile/no partner	0.28	0.17–0.45	0.001	11.2	6.70–18.78	0.001
Discussion with health worker about contraception	Yes	1.00			1.00
	No	0.59	0.47–0.74	0.001	0.71	0.55–0.91	0.008
Contraception is women’s business	Disagree	1.00			1.00
	Agree	0.56	0.46–0.69	0.001	0.67	0.52–0.85	0.001
	Don’t know	0.29	0.19–0.44	0.001	0.52	0.31–0.87	0.014
Women using contraception become promiscuous	Disagree	1.00			1.00
	Agree	1.78	1.34–2.35	0.001	1.07	0.77–1.47	0.675
	Don’t know	1.59	1.09–2.30	0.014	1.05	0.73–1.51	0.778

Discussion

The policy paper of Ministry of planning, development and special initiatives 2020 stated various measures to improve contraceptive prevalence rate including development of skilled human resource, adequate supply of modern contraceptives, targeting female population with high risk fertility etc. [24]. Evidence suggests that encouraging men to be supportive partners for contraceptives use improves health outcomes. More recently, the role of men in family planning is being evolved from “supportive partners” to active users of family planning services and to improve their own reproductive health as well. This indicates why there is a pressing need to approach men in family planning and reproductive health matters [25].

This study examined the factors associated with modern contraceptive use among Pakistani men using the data of Pakistan demographic and health survey 2017–18. Education, region, socioeconomic status, fertility preference, the perception that contraception is women’s business and discussion of family planning with health workers were significant predictors of modern contraceptive usage in Pakistani men.

Findings of this paper highlighted that men who discussed family planning with a healthcare worker had a higher likelihood of using modern contraceptive methods. This finding is in line with the findings from a study conducted in Uganda. Evidence from behavior change models suggests that knowledge is the first step towards change in behavior [26]. Discussion with a health worker about family planning enhances the knowledge of contraception that ultimately brings a positive change in behavior [27]. Similar findings were also reported by studies conducted in Congo [28] and Tanzania [29].

Wealth index also came out to be a significant predictor of modern contraceptive use. Findings from a study conducted in Myanmar also suggested a lower likelihood of modern contraceptive use among men belonging to poor wealth quintile [30]. In addition, the findings of DHS surveys conducted in 18 countries of Latin America, Africa, Caribbean and Asia also supported this finding [31].

In agreement with the findings of this paper, a study conducted in Uganda found that men with higher education were more likely to use modern contraception compared to those who received no formal education [32]. Education helps to get employment which, in turn, increases “household income”: a predictor of modern contraceptive use [32]. Certain other studies also reported similar findings on education and wealth index as predictors of modern contraceptive use [33, 34].

This study found significantly less likelihood of modern contraceptive use among men residing in Baluchistan and FATA. A study from Pakistan showed lesser use of contraceptive methods among the residents of Baluchistan relative to other provinces especially Punjab. The probable explanation for this finding is improved structure of family planning services in Punjab [13]. A report was published on the ranking of various provinces of Pakistan based on conduciveness to family planning services. The report discussed various socio-demographic parameters that are linked to contraception uptake, e.g. a better female literacy rate in Punjab (62%) compared to other provinces of Pakistan (Sindh 44%, KPK 35% and Baluchistan 16%). In addition, better utilization of antenatal care services and a higher proportion of economically active women, as described in the said report, may also partly explain why Punjab outperformed in contraceptives uptake relative to other regions [35]. Another previous study also reported that the use of modern contraception varied across various regions of the country [36].

Men who showed no desire for another child were more likely to report modern contraceptive use in a study carried out in Kenya, a finding consistent with the results of this study [37]. Another study showed that men who were infertile or had no partner were more likely to use modern contraceptive methods when compared to those who wanted additional children [1]. Men who do not have a legit partner are more likely to use contraception in order to avoid fathering an illegitimate child which is socially unacceptable [38].

This study also found that men who believed that contraception was women’s business were significantly less likely to use modern contraceptive methods. This finding is in compliance with a study from Nigeria which states that negative attitudes of men towards family planning adversely affect modern contraceptive uptake among women [39].

The findings of this study are influenced by recall bias, which represents a potential limitation of the study. In addition, a causal relationship between outcome and predictors cannot be established due to cross-sectional nature of this survey. There were various potential independent variables like parity, sexual activity and marital status which could be incorporated in this analysis. However, the data on these variables could not be retrieved from the dataset. Moreover, This study measured how various predictors influence men’s behavior to use contraception. It did not differentiate between men who used male methods from those who relied solely on female methods of contraception. This represents a potential area which can be explored in future studies.

Conclusion

The role of men in family planning is critical in patriarchal societies like Pakistan. Men who are uneducated, belong to poor socioeconomic status, residents of underprivileged areas, and men having false perceptions (contraception is women’s business) are less likely to use contraception. Educating males about reproductive health to eradicate false perceptions about contraception are recommended to improve the efficiency of family planning services in Pakistan. In addition, women empowerment and reproductive health education will also improve contraceptive uptake by couples. Appropriate policy needs to be formulated to ensure the engagement of men in family planning programs, e.g. by encouraging the involvement of men in family planning discussions or counselling sessions. This is because the objectives of family planning programs may not be met without considering the role of men as chief decision makers in patriarchal societies. The findings of this study may contribute to the achievement of Pakistan’s commitment to increase the contraceptive prevalence rate by 60% in 2030.

STROBE checklist.

(DOC)

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Findings of collinearity diagnostics (tolerance statistics and variance inflation factor).

(DOCX)

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Descriptive table on various contraceptive methods.

(DOCX)

Click here for additional data file.

(SAV)

Click here for additional data file.

29 Mar 2022

Determinants of modern contraceptive use among men in Pakistan: evidence from Pakistan demographic and health survey 2017-18

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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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: The research article “Determinants of modern contraceptive use among men in Pakistan: evidence from Pakistan demographic and health survey 2017-18” uses secondary data analysis of Pakistan Demographic and Health Survey (DHS) to explore the determinants of modern contraceptive use among men.

The study is important as the unmet need for family planning in Pakistan is high and male´s attitudes regarding contraception are an important part of fertility rates.

Background

Consider changing the word “determinants” to “factors associated with”, as DHS do not have a longitudinal design, thus cannot be utilized to study causality.

The author says that U$ 55 are spent per woman, but it is not clear if it is a yearly rate.

As much as the authors cite the relevant factors that matter for the utilization of modern contraceptive among men and bring some of these factors in the discussion (socioeconomic status, education, cultural beliefs, area of residence, religion and wrong perceptions about family planning), it would be interesting to hear more about these mechanisms up front. I would add a section containing a brief review of these factors, especially because testing these elements is the main goal of these analyses.

The same goes for research studies “exploring the predictors of contraceptive use among couples have overlooked the role of men”. The authors should bring more of this literature and how their study contributes to this framework.

The following phrase is misplaced: “In agriculture based societies, men usually wish to have large number of children because they serve as a source of livelihood. This perception of men creates hinderance in the utilization of contraceptives by couples [18][19][20]”. This is an example of a mechanism and should be included in the section I suggest you add.

The findings would also benefit from more background regarding the regions explored (Punjab, Sindh, KPKa, and so on). Why would I expect regions to differ regarding contraception use? Could levels of development and indicators of gender equity (such as female illiteracy rate) be used to explain some of these differences observed? What has the literature said of these places? You explain Punjab may have improved the structure of family planning services. I would like to hear more about it.

In the end of the Background section, the authors highlight the importance of their findings to frame family planning programs considering the role of men as decision makers in the matters of family planning and reproductive health in patriarchal societies. I think this is gold and should be brought up again in the results with clear and stated recommendations.

I also suggest you enrich your review by bringing information about factors associated with contraceptive use for Pakistan women.

Methods

The analysis was done carefully and the method is adequate for the research question. However, I think it is important to insert controls for parity and if men are sexually active.

I also think it would be good to leave age as a continuous variable, unless you have reasons to believe those three age groups should remain separate.

Being a DHS, it is important to provide information regarding survey weights and sampling.

I understand that calculating a Wealth Index using quintiles would automatically separate the observations into five groups with approximately the same number of respondents. So, these phrase is irrelevant: “Each wealth quintile had an approximately similar number of respondents”.

Regarding the logistic regression, I understood from the text that authors only used in the multivariate analysis the variables that had been found to be significant in the bivariate model. However, by looking at Table 3, all variables were included (indeed, they are all significant at the bivariate model). I would add a phrase explaining that they are all significant. If it is not what you did, please, clarify.

Conclusion

I think this manuscript would benefit from a Review as it has the potential to make a good contribution in its field.

Reviewer #2: The question of fertility plays a vital role in many countries’ economic development and health objectives, including Pakistan. It is, therefore, an important area for investigation and the use of large datasets such as the demographic and health survey (PDHS). I appreciate the authors’ curiosity and diligence in investigating this area. Hopefully, my comments can be used to enhance the work.

Introduction

On page 03, line 51, the reference to fertility reduction as being connected to improvements in health and economic activity is a bit vague. Are you referencing individuals or the state of the country as a whole? Also, it is a bit of a nuanced argument that would require some expansion. However, your study seems more concerned with reaching the male population and less of the significant picture objectives, perhaps focusing on the male perspective. Why have males historically been left out of the conversation on family planning? Why has it taken so long to recognize the importance of reaching out to males in that space? Why have previous efforts tended to focus on women?

On page 4, Line 73 -Line 74, you refer to the United Nations International Conference on Population and Development. That was more than a generation ago, and there have been many iterations of global, regional, and country-specific policies and objectives that have addressed some of the questions you are investigating in this paper. Perhaps you should reference something more recent (e.g., the Millennium Development Goals, followed by the SDGs). Even the UN ICPD had a 25th reunion (i.e., the Nairobi Summit). How have such global structures framed the issue of fertility and contraceptive use behaviors?

Methods

The methods read as straightforward and well-executed. I have nothing to add to this section except for the choice of the conceptual framework. Why was that framework chosen? What is the justification for choosing to look at the variables of interest through that lens? Several conceptual frameworks have been used over the years to explain contraceptive use and family planning behaviors (e.g., USAID’s Conceptual Framework and the Women’s and girls’ empowerment in sexual and reproductive health (WGE-SRH) framework). Why did you eschew other frameworks in favor of this one?

As a note, Figure 01 is blurry, and I think you should find a better image that is clearer and easier to read.

Results

Be careful of the language you employ in describing your results. For example, in the results section, you use the terms likelihood and odds interchangeably. Though they are used to mean the same thing in colloquial usage, “odds” references a particular relationship between the ratio of probabilities (see pg. 10, Line 171 compared to Line 175).

Also, be sure to state that a finding is statistically significant and not just significant. Again, statistically significant as a technical term references something particular, while a finding being “significant” can have a more general meaning, such as being generally important or worth noting.

Discussion

The paper’s discussion section is an excellent place to explore your findings and their potential impact. As I read through this section, it mostly reads as a reiteration of the results section. Try exploring some of the following areas:

Given that in the introduction, you mention that your findings may be used to inform policy, I was hoping the discussion would delve into some commentary about Pakistan’s policy regarding modern contraceptive use if there is one, and how findings can influence that. The fertility challenges have been documented for many decades now and I, as a reader, assume that there are some policies already in place. How do your findings impact those kinds of initiatives? Are men historically excluded from those policies? If men as a subgroup have factored into such initiatives, what do these findings mean?

On pg. 13, Line 217 to Line 222, you note regional differences, particularly between Punjab and other regions. You theorize that it may be due to improve family planning programs. Is it possible to expand a bit on this? What kind of well-structured family planning programs in Punjab make that place more successful than other regions, and why have such policies not been diffused to other regions.

Why do you relate your study findings to findings from places like Uganda and Congo? There is nothing wrong per se with that comparison; I don’t think. You could argue that Pakistan occupies a similar socio-economic bracket as those countries, and hence the way they deal with contraceptive use and family planning behaviors may have some bearing on Pakistan. However, neighboring countries in the subregion (e.g., India, Tajikistan, Afghanistan, and Iran) may offer more forthright comparators. I suggest looking through the literature.

Reviewer #3: Review Comments to the Author

Dear Editor,

Thank you for the opportunity to review the manuscript titled Determinants of modern contraceptive use among men in Pakistan: evidence from Pakistan demographic and health survey 2017-18.

Overall, the manuscript is fairly well written and has clear aims. It also focuses on a topic of deep interest to the reproductive health community and is backed by an extensive body of research. However, I find that the justification for the study and its relative contribution to the existing literature is very weak. As such, the unique contribution of these analysis is unclear to me. I think the authors can make a stronger case if they could point out which variables have not been examined, whether is consensus and variables that have inconsistent results. Please see below my specific comments that could further improve the manuscript.

Introduction

Overall – Fairly clear and well written.

1. There are multiple typos throughout the manuscript. Authors are suggested to proofread them carefully.

2. Consider reporting on how Pakistan compares in relation to regional estimates of modern contraceptive use.

3. Need to define modern contraceptives.

4. If effective strategies need to be country-specific, what was the rationale behind estimating prevalence? The rationale part needs to be strengthened.

Methods

1. Data sources and sampling techniques – could benefit from better organization structure – information seems randomly placed. Also, expand on stratification and provide a reference for a more elaborate description for the DHS sampling strategy.

2. Sample –Provide a justification for your sample selection

3. Please provide another Table and give how each of the independent variables were derived or recoded from the original dataset. This can either be in the manuscript or attached as a supplementary file.

4. Which sampling weight and id were used and was the weight normalized?

5. What informed the inclusion or selection of the independent variables?

6. Please specify the model equation

7. What informed the choice of the reference categories

8. Did the authors check for multi-collinearity, the results should be provided

9. Please use the STROBE guidelines and present it as an appendix or a supplementary file

Results

1. Consider specifying only the key findings of the study rather than listing all the determinants. Also, use the breakdown of the sentences rather than writing one long sentence that is hard to follow.

2. The statistical analysis not been performed rigorously

3. Presentation of results needs to be revised

Discussion

1. Authors started to compare and contrast study findings, which should have been followed after stating the key findings and justification for those findings.

2. There is a repetition of most of the findings that are already stated under the results section.

3. Justification for all the discordant results are presented same i.e., due to differences in sample size, study design, setting, and study population. This needs to be study specific rather than a mere generalization.

Conclusion

1. Clearly and concisely state the conclusions of the study in relation to the key question it sought to answer and the contribution that the paper would make.

2. The conclusion is well presented. However, the policy implications are not well discussed. The authors can consider beefing them up.

**********

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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Submitted filename: Review - PONE-D-21-23985 (1).pdf

Click here for additional data file.

9 May 2022

Reviewer no. 1

• Consider changing the word “determinants” to “factors associated with”, as DHS do not have a longitudinal design, thus cannot be utilized to study causality.

The suggested change has been made.

• The author says that U$ 55 are spent per woman, but it is not clear if it is a yearly rate.

The suggested change has been made in line no. 61.

• As much as the authors cite the relevant factors that matter for the utilization of modern contraceptive among men and bring some of these factors in the discussion (socioeconomic status, education, cultural beliefs, area of residence, religion and wrong perceptions about family planning), it would be interesting to hear more about these mechanisms up front. I would add a section containing a brief review of these factors, especially because testing these elements is the main goal of these analyses.

Additional information from relevant literature explaining the mechanisms of various predictors on contraception has been added as per the reviewer’s suggestion (line 73-80).

• The same goes for research studies “exploring the predictors of contraceptive use among couples have overlooked the role of men”. The authors should bring more of this literature and how their study contributes to this framework

Additional information from relevant literature has been added as per the reviewer’s suggestion (line 93-94).

• The following phrase is misplaced: “In agriculture based societies, men usually wish to have large number of children because they serve as a source of livelihood. This perception of men creates hinderance in the utilization of contraceptives by couples [18][19][20]”. This is an example of a mechanism and should be included in the section I suggest you add.

I appreciate reviewer’s efforts and keen interest in my manuscript. The phrase has been repositioned (line no. 71-73).

• The findings would also benefit from more background regarding the regions explored (Punjab, Sindh, KPKa, and so on). Why would I expect regions to differ regarding contraception use? Could levels of development and indicators of gender equity (such as female illiteracy rate) be used to explain some of these differences observed? What has the literature said of these places? You explain Punjab may have improved the structure of family planning services. I would like to hear more about it.

Ministry of national health services regulation and coordination, Pakistan published a report that commented on the ranking of various provinces of Pakistan based on their conduciveness to contraception services. The report pointed out that because of better female literacy rate, women empowerment, better utilization of antenatal care services, contraception prevalence is better in Punjab. This information is incorporated in line no. 261-267.

• In the end of the Background section, the authors highlight the importance of their findings to frame family planning programs considering the role of men as decision makers in the matters of family planning and reproductive health in patriarchal societies. I think this is gold and should be brought up again in the results with clear and stated recommendations.

I am thankful to the reviewer for highlighting an important area of the introduction and its relevance to results and conclusion.

• I also suggest you enrich your review by bringing information about factors associated with contraceptive use for Pakistan women

The study intends to look for the factors associated with modern contraceptive use in men. Authors have tried to put together the most pertinent information from the literature. Additional information on women related factors may unduly prolong the introduction section and may appear disconnected from the rest of the literature.

• The analysis was done carefully and the method is adequate for the research question. However, I think it is important to insert controls for parity and if men are sexually active.

I appreciate the encouraging remarks of the reviewer. Data on “parity” and “if men are sexually active” could not be fetched from the dataset.

• I also think it would be good to leave age as a continuous variable, unless you have reasons to believe those three age groups should remain separate

Age was originally a categorical variable in dataset consisting of 5 years age groups. However it was recoded and divided into three classes for the ease of data interpretation.

• I understand that calculating a Wealth Index using quintiles would automatically separate the observations into five groups with approximately the same number of respondents. So, these phrase is irrelevant: “Each wealth quintile had an approximately similar number of respondents”.

The said phrase has been removed.

• Regarding the logistic regression, I understood from the text that authors only used in the multivariate analysis the variables that had been found to be significant in the bivariate model. However, by looking at Table 3, all variables were included (indeed, they are all significant at the bivariate model). I would add a phrase explaining that they are all significant. If it is not what you did, please, clarify.

All the variables except “employment status” were significant in bivariate analysis. Therefore, rest of the variables were recruited into multivariable model. The modification is present in line no. 162-164.

Conclusion

• I think this manuscript would benefit from a Review as it has the potential to make a good contribution in its field.

We are thankful to the editorial team and worthy reviewers for their valuable time and considering our study for peer review. Your comments are really valuable in improving the manuscript.

Reviewer no. 2:

The question of fertility plays a vital role in many countries’ economic development and health objectives, including Pakistan. It is, therefore, an important area for investigation and the use of large datasets such as the demographic and health survey (PDHS). I appreciate the authors’ curiosity and diligence in investigating this area. Hopefully, my comments can be used to enhance the work.

Introduction

• On page 03, line 51, the reference to fertility reduction as being connected to improvements in health and economic activity is a bit vague. Are you referencing individuals or the state of the country as a whole? Also, it is a bit of a nuanced argument that would require some expansion.

The said line has been eliminated.

However, your study seems more concerned with reaching the male population and less of the significant picture objectives, perhaps focusing on the male perspective. Why have males historically been left out of the conversation on family planning? Why has it taken so long to recognize the importance of reaching out to males in that space? Why have previous efforts tended to focus on women?

The generalized perception about “contraception being a women’s business” is largely responsible for keeping males from family planning programs target. The importance of male involvement particularly in patriarchal societies was recognized aa few decades back. International conference on population and development held in Cairo was among the initial historical landmark that endorsed the involvement of men in family planning programs. The relevant literature is stated in the Introduction section.

• On page 4, Line 73 -Line 74, you refer to the United Nations International Conference on Population and Development. That was more than a generation ago, and there have been many iterations of global, regional, and country-specific policies and objectives that have addressed some of the questions you are investigating in this paper. Perhaps you should reference something more recent (e.g., the Millennium Development Goals, followed by the SDGs). Even the UN ICPD had a 25th reunion (i.e., the Nairobi Summit). how have such global structures framed the issue of fertility and contraceptive use behaviors?

The ICPD held in Cairo was an important historical landmark that drew attention towards the role of men in family planning. Furthermore, Reference from international conference on population and development held in Nairobi has also been cited in the introduction (line no. 86-90).

Methods

• The methods read as straightforward and well-executed. I have nothing to add to this section except for the choice of the conceptual framework. Why was that framework chosen? What is the justification for choosing to look at the variables of interest through that lens? Several conceptual frameworks have been used over the years to explain contraceptive use and family planning behaviors (e.g., USAID’s Conceptual Framework and the Women’s and girls’ empowerment in sexual and reproductive health (WGE-SRH) framework). Why did you eschew other frameworks in favor of this one?

USAID conceptual framework is designed to assess the impact of family planning on various areas of women’s lives i.e. personal autonomy, health status, economic resources and acquisition of education etc. Whereas, our study intends to assess the factors that influence contraceptive uptake. Considering the research question and the available data, authors found the employed conceptual framework to be more pertinent.

• As a note, Figure 01 is blurry, and I think you should find a better image that is clearer and easier to read.

The image quality has been improved. Modified image is uploaded with the revised manuscript.

Results

• Be careful of the language you employ in describing your results. For example, in the results section, you use the terms likelihood and odds interchangeably. Though they are used to mean the same thing in colloquial usage, “odds” references a particular relationship between the ratio of probabilities (see pg. 10, Line 171 compared to Line 175).

The issue has been rightly raised. Appropriate changes have been made in the results section (line 203 and 210).

• Also, be sure to state that a finding is statistically significant and not just significant. Again, statistically significant as a technical term references something particular, while a finding being “significant” can have a more general meaning, such as being generally important or worth noting.

Authors understand the point raised by the worthy reviewer. Findings have been reported appropriately in this regard.

Discussion

The paper’s discussion section is an excellent place to explore your findings and their potential impact. As I read through this section, it mostly reads as a reiteration of the results section. Try exploring some of the following areas:

• Given that in the introduction, you mention that your findings may be used to inform policy, I was hoping the discussion would delve into some commentary about Pakistan’s policy regarding modern contraceptive use if there is one, and how findings can influence that. The fertility challenges have been documented for many decades now and I, as a reader, assume that there are some policies already in place. How do your findings impact those kinds of initiatives? Are men historically excluded from those policies? If men as a subgroup have factored into such initiatives, what do these findings mean?

A brief section has been added in the discussion section that highlights the policy in place for improvement of contraceptive prevalence in Pakistan. The section indicated that there is no clear policy in place that dictates the measures to encourage the involvement of men in family planning and decisions related to contraception (line no. 232-237).

• On pg. 13, Line 217 to Line 222, you note regional differences, particularly between Punjab and other regions. You theorize that it may be due to improve family planning programs. Is it possible to expand a bit on this? What kind of well-structured family planning programs in Punjab make that place more successful than other regions, and why have such policies not been diffused to other regions.

A brief explanation on regional variation in contraception usage has been added (line no. 261-267)

• Why do you relate your study findings to findings from places like Uganda and Congo? There is nothing wrong per se with that comparison; I don’t think. You could argue that Pakistan occupies a similar socio-economic bracket as those countries, and hence the way they deal with contraceptive use and family planning behaviors may have some bearing on Pakistan. However, neighboring countries in the subregion (e.g., India, Tajikistan, Afghanistan, and Iran) may offer more forthright comparators. I suggest looking through the literature.

The reviewer has rightly pointed out the rationale behind citing literature from places like Tanzania and Congo. Because of similar socioeconomic conditions, the findings from these regions may apply to the subcontinent as well.

Reviewer no.3:

Dear Editor,

Thank you for the opportunity to review the manuscript titled Determinants of modern contraceptive use among men in Pakistan: evidence from Pakistan demographic and health survey 2017-18.

Overall, the manuscript is fairly well written and has clear aims. It also focuses on a topic of deep interest to the reproductive health community and is backed by an extensive body of research. However, I find that the justification for the study and its relative contribution to the existing literature is very weak. As such, the unique contribution of these analysis is unclear to me. I think the authors can make a stronger case if they could point out which variables have not been examined, whether is consensus and variables that have inconsistent results. Please see below my specific comments that could further improve the manuscript.

Introduction

Overall – Fairly clear and well written.

• There are multiple typos throughout the manuscript. Authors are suggested to proofread them carefully.

The manuscript has been carefully proof-read. Any typo that was detected has been corrected and highlighted.

• Consider reporting on how Pakistan compares in relation to regional estimates of modern contraceptive use.

The estimates on contraceptive prevalence rate of India and Bangladesh has been added (line no. 56-57).

• Need to define modern contraceptives.

Modern contraceptives, being a dependent variable of the study, has been defined in methodology.

• If effective strategies need to be country-specific, what was the rationale behind estimating prevalence? The rationale part needs to be strengthened.

This study did not estimate any prevalence. With respect I would like to say that the rationale part was written carefully. I would like to refer to the comment of reviewer one that says:

“In the end of the Background section, the authors highlight the importance of their findings to frame family planning programs considering the role of men as decision makers in the matters of family planning and reproductive health in patriarchal societies. I think this is gold and should be brought up again in the results with clear and stated recommendations.”

Methods

• Data sources and sampling techniques – could benefit from better organization structure – information seems randomly placed. Also, expand on stratification and provide a reference for a more elaborate description for the DHS sampling strategy.

The sampling procedure used in PDHS 2017-18 has been added to the methodology section (line no. 109-117). A reference for the details of sampling collection technique used in the survey has been added (line no. 124-125). The information has been placed in a structured format. Information related to PDHS survey, data collection procedure is placed under the section of “data source”. This was followed by the definitions of variables used in the study. Finally. The statistical analysis used in this study was explained.

• 2. Sample –Provide a justification for your sample selection

The sample consisted of 15-49 years old ever married men. This sample was used because the data on contraception was available only for the said bracket of men in PDHS dataset.

• 3. Please provide another Table and give how each of the independent variables were derived or recoded from the original dataset. This can either be in the manuscript or attached as a supplementary file.

Only two variables (education and age) were recoded. The details on how the said variables were recoded from the original dataset have been incorporated into the manuscript (line no. 151-153)

• 4. Which sampling weight and id were used and was the weight normalized?

Men’s sample weights were used from PDHS dataset. The ID of the weight variable in men’s PDHS dataset was “mv005”. Weights normalization was not carried out.

• What informed the inclusion or selection of the independent variables?

Available data and literature survey guided the recruitment of independent/predictor variables.

• Please specify the model equation

Upon reading various published studies in impact factor journals, it was found that most of the studies do not include the statistical equation in the methodology. As all of the tests are run in software, it is usually not necessary to have an in depth mathematical understanding of the statistical models to run these tests. However, if it is an essential requirement, authors will seek guidance from the statistician to help specify an equation for our model.

• What informed the choice of the reference categories

Previous studies were explored for this purpose. In addition, the reference categories were selected based on the hypothesis e.g. “residents of Punjab” and “educated men” were anticipated to have a higher modern contraception uptake. Thus, these were selected as reference categories to check how these categories differ relative to their counterparts.

• 8. Did the authors check for multi-collinearity, the results should be provided

Yes. Multicollinearity was checked. The results have been added as a supplementary file named “S1 text”.

• 9. Please use the STROBE guidelines and present it as an appendix or a supplementary file

STROBE guidelines were used during manuscript write-up. A strobe checklist has been attached as a supplementary file named “S2 text”.

Results

• Consider specifying only the key findings of the study rather than listing all the determinants. Also, use the breakdown of the sentences rather than writing one long sentence that is hard to follow.

Authors respect this concern of the reviewer. The results are already tailored to the key findings. Authors have gone through them in detail. None of them needs to be deleted. In addition, no sentence is long enough to interrupt the continuity of the reader.

• The statistical analysis not been performed rigorously

Critical comments are a great avenue for self reflection and learning. The statistical analysis was reviewed in detail. Reviewer 1 and 2 have also endorsed that data analysis is adequately carried out. Moreover, Authors have tried their level best to respond to the comments of each reviewer raised on statistical analysis.

Discussion

• Authors started to compare and contrast study findings, which should have been followed after stating the key findings and justification for those findings.

A summary of the study findings is added before discussing each of them separately (line no. 229-232). The justification for all the findings is appropriately provided. Wherever deficient, as indicated by the previous reviewers additional information has been incorporated to give a robust justification of the results. E.g. line 232-237 and line 261-267.

• 2. There is a repetition of most of the findings that are already stated under the results section.

There is no reiteration of the findings per se in the discussion, however these are mentioned in order to compare them with the previous studies of similar kind.

• 3. Justification for all the discordant results are presented same i.e., due to differences in sample size, study design, setting, and study population. This needs to be study specific rather than a mere generalization.

There is no such recurring justification based on study population, design or sample size in the discussion section. Moreover, various modifications have done in the discussion section which have led to improvements in the justification of reported findings.

Conclusion

• Clearly and concisely state the conclusions of the study in relation to the key question it sought to answer and the contribution that the paper would make.

The conclusion section has been enriched with the policy recommendation and the importance of its potential to contribute to the improvement of contraception prevalence has been added (line 286-290).

• 2. The conclusion is well presented. However, the policy implications are not well discussed. The authors can consider beefing them up.

I appreciate the reviewer’s encouraging remark. The policy implication has been added to the conclusion (line 286-290).

Submitted filename: RESPONSE TO REVIEWRS.docx

Click here for additional data file.

30 May 2022

Submitted filename: Review 02 - PONE-D-21-23985R1.pdf

Click here for additional data file.

30 Jul 2022

Reviewer #1:

Introduction

I would like to say that I appreciate the authors' effort to improve the paper according to the reviewers' points. It has been completely revised and has improved considerably.

One thing to consider is that by adding the information requested by the reviewers, the manuscript lost a lot of its readability. So, I would spend some time trying to improve the flow of information. For example, line 50 mentions the role of contraceptives in preventing maternal mortality, but line 65 bring the proportions of death. Another example further down: Line 252 to 263 brings several short phrases that can be better connected. See for example, that the word Punjab appears 5 times in this solo paragraph. By the way, you improved this part, but I think we need more descriptions of these regions and their components (because maybe the differences we are observing are only compositional effects)

I agree with the reviewer’s suggestions. The incorporation of new information in the revised version impaired the continuity of information at certain areas. The said rearrangements have been made (line no. 52-54).Furthermore, referring to the 2nd part of the comment, Line 280-287 have been edited and rephrased.

I would like to strength the point that we have here a paper on a topic that is not very well explored, which is male´s involvement in contraceptive use. Studies inquiring males are absolutely necessary in order to help inform reproductive change policies. Nevertheless, for most modern contraceptives, excluding male condom and vasectomies, women are the ones taking the contraceptives, so, any study of male´s contraceptive behavior is at least partially explained by their female partners´s access and use of contraceptive. This should be mentioned upfront as well as an important consideration which is: women might be taking contraceptives without men knowing about them. So, it is important to either compare this distribution to women´s prevalence or at least mention this statement. You are basically evaluating men´s contraceptive use based on what they know is true.

A similar comment was also raised below. This is a genuine point that I fully agree with. The relevant statements have been written (line no. 303-307).

In my previous review, I listed several points that needed to be observed. In this new submission, the authors addressed one by one, like improving the description of mechanisms of various predictors on contraception, adding background information on each of the regional areas, improving the importance of their findings to frame family planning programs considering the role of men as decision makers and also included a short section explaining why men has been left out of the conversation on family planning (as suggested by the other reviewer). However, I would also add the SDGs as your own justification for this kind of work and I would increase this part in the Discussion section as I will explain below.

I appreciate the encouraging remarks quoted by the worthy reviewer. The comments raised below have been carefully addressed.

As no section “Liteture Review” as presented, the authors brings the literature review at the discussion. I don´t personally like this format, but it is ok. I will comment about it at the “Discussion” section.

The comments in the discussion section have been carefully read and acted upon wherever appropriate.

Methods

As I mentioned before, it would be important to control for parity and sexual activity. As the authors mention that this information could not be retrieved from the dataset, this limitation should be listed in the discussion. The same goes for age as a continuous variable, that they don´t have. The variables “age” and “education were recoded, but it is necessary to provide the original categories. As for the other ones, it is important to specify that they are being used in their original format.

I agree with the reviewer’s opinion. The raised points have been added as a limitation in the discussion section (line no. 299-307). The readers can refer to the datasets for original categories as the data is freely available on DHS website.

I also think the analysis should be controlled by marital status. Could part of this ever-married men be widow or separated?

Out of 3691 ever married women, only 63 men were separated, widowed or no longer living together. The data on contraception for these men was missing in the dataset. That’s why we couldn’t control our analysis for marital status (line no. 302).

I also would like to see a descriptive table of all contraceptive methods before being aggregate into modern or traditional. Mainly because I would like to see if men who use condoms are different from male who use female´s methods. Aggregating into modern methods may make us lose important variability.

A descriptive table has been added as a supplementary file that segregates men based on the contraceptives they are using (S3 text).

As per another reviewer indicated and it remained missing, I think they should include the information about having used man´s sample weights and the information about choice of reference category in the logistic regressions.

The information about having used men sample weights has been added (line no. 158-159). Choice of reference category has been explained at line no. 170-174.

Discussion

Again, I think the incorporation of the reviews made the text lose readability. Check, for example, the first paragraph of the discussion. A great start would be to use “The policy paper…(line 227 to 232) ” and then finish with the lines 223 to 227, which are the empirical findings.

The sentences have been rearranged (line no.234-238 repositioned to line no. 249-253).

The second paragraph also present structural problems that distract the reader. See how both phrases below can be transformed into a single one:

235 - Discussion with a health worker about family planning enhances the knowledge of contraception that ultimately brings a positive change in behavior [27].

237 - Evidence from behavior change models suggest that knowledge is the 238 first step towards change in behavior [28].

You either flip these phrases or reframe them. This happens throughout the Discussion, so be patient to improve these sentences and paragraphs.

The phrases have been repositioned (from line no. 259-260 to line no. 256-257).

As I pointed in the “Introduction” section, here they keep on adding previous empirical evidence found in the literature with which their findings converse. This is important, as I had mentioned in my first review. But in a journal such as PLOS one, you need to go one step further and discuss why it is important to incorporate men (you cite this on line 231 but do not explore) and how your unique findings help frame family planning programs considering the role of men as decision makers. That means: why is your article unique? How can these findings help Pakistan, which have historically excluded men (as pointed by reviewer 3), create policies that will sucessfully involve men?

Further explanation on how the role of men in family planning has evolved over time and why it is important to incorporate them in family planning programs has been added (line no. 243-248)

The Conclusion section summarizes all of these really well, but the things above mentioned should be first introduced and dissected in the Discussion sections. They all have mechanisms (i.e. female literacy empower women to demand contraceptives? Or female literacy is associated with male´s literacy, so men who with higher levels of education would be more aware about contraceptive methods and will tend to report more).

Authors agree with the reviewers remarks. A plausible explanation/mechanism of each finding has been added at respective places.

By the way, always keep in mind that the statistics pertain to “men´s perception of contraceptive use”. It is possible that women use contraceptives, yet their husbands don´t know or don´t care to know. So what you are measuring is perception, not use. In my understanding, the only “use” you can measure is vasectomies and condoms. Any data on couple´s discordance on contraceptive methods that you could bring? If not, them set this for future studies.

I am thankful to the reviewer for highlighting a very important aspect of this analysis. The statistics of this analysis reflect the predictors men’s behavior/perception towards contraception. If there is any difference between the men who use “male methods” and those who rely on “female methods” could be a potential area for a future study. All the authors appreciate the reviewer for keenly reviewing the manuscript and making a heartful effort to improve the manuscript. The relevant statements have been written (line no. 303-307).

Reviewer’ 2

Overall, great job in addressing my concerns from the first submission. I think the paper is ready to move forward. I would suggest a few more minor edits and things to consider. Please see my comments below.

You did not state the significance level in the Statistical Analysis section. Your audience needs to know the cutoff for statistical significance. I assume it is 0.05?

Level of significance has been stated (line no. 168-169)

Results Consider using two decimal places for the reported statistics even in your tables. Honestly, there is no need to use more than 2 in a study of this type. Furthermore, two decimal places improves readability. I noticed this in Table 3, but consider creating a list of abbreviations/acronyms at the end of your article rather than using superscripts to designate the acronym. For example, FATA means, Federally Administered Tribal Areas. A list of abbreviations/acronyms would make for easy referencing.

The said changes have been made. Abbreviations have been written on line no. 321-326.

Discussion Line 247 - 248 You cannot, or perhaps should not, draw this type of conclusion. Yes, contraceptive use is strongly associated with the man's household socioeconomic bracket (measured by the Wealth Index). Will simply increasing household wealth improve contraceptive use? And who is to improve household income? Since you are looking at population-level data, I assume that will be the government? Are there no other confounding factors that mediate the relationship between wealth and contraceptive 2 use that may offer a better point for policy to address? Lastly, the Wealth Index used in the DHS program is a generalized measure that allows broad comparisons at the population level. Measures of wealth using income and expenditure would give more robust evidence for that association and thus would be better support for that conclusion, which could be a study for another time.

Author’s agree with the reviewer’s stance. The concerned line has been deleted (line no.264-265).

Your discussion section is missing an element. I think you are missing a paragraph on study limitations.

A detailed paragraph o n limitations has been added in the discussion (line no. 299-307).

Conclusion Line 286-287 What kind of policy do the authors recommend? Do you have any suggestions s from the references that will help Pakistan achieve a contraceptive prevalence rate of 60% by 2030? I bring this up because you are the experts; you have studied the statistics and provided us with some answers, so from your analysis, what would be your policy recommendations? The conclusion offers you the opportunity to be a bit more specific and direct (this is just a suggestion, as it is fine as written).

Various policy recommendations are mentioned in the conclusion section. A slight modification has been done in line no. 316-317.

18 Aug 2022

Factors associated with modern contraceptive use among men in Pakistan: evidence from Pakistan demographic and health survey 2017-18

PONE-D-21-23985R2

Dear Dr. Ali,

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

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Reviewer #3: All comments have been addressed

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Reviewer #1: I thank the authors for significantly improving the manuscript. I do not have anything else to add to my comments and if the authors have done what they can to address my previous suggestions, I believe it is good for publication.

My only comment is that I am still missing a brief discussion about how you are actually analysing perceptions when it comes to female methods, especially since you find that men who believe contraception is a women's business are less likely to report using contraception. This seems obvious because they might not know about their women's behavior. So, they are less likely to report, but not necessarily less likely to use (a female method, for example, that he is not aware). As you are not pairing women and men's data, there is no way for you to check whether your finding is true. So, I would rephrase your findings to reflect perception, not real behavior.

Reviewer #3: Author's made vast changes in their manuscript. The manuscript is now quite good for publication in PLOS ONE. No additional comments from my side.

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23 Aug 2022

PONE-D-21-23985R2

Factors associated with modern contraceptive use among men in Pakistan: evidence from Pakistan demographic and health survey 2017-18

Dear Dr. Ali:

I'm 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 let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, 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.

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