Factors associated with use of long-acting reversible and permanent contraceptives among married women in rural Kenya: A community-based cross-sectional study in Kisii and Kilifi counties.

Long-acting and permanent contraceptive methods (LAPM) are effective and economical methods for delaying or limiting pregnancies, however they are not widely used. The Kenya government is promoting the use of modern methods of family planning through various mechanisms. This study aimed to determine the prevalence and factors associated with the use of LAPM among married women of reproductive age in targeted rural sub-counties of Kilifi and Kisii counties, Kenya. Baseline and end line Data from a program implemented on improving Access to Quality Care and Extending and Strengthening Health Systems (AQCESS) in Kilifi and Kisii counties of Kenya were used. Multi-stage sampling was used to sample 1117 and 1873 women for the end line and baseline surveys, respectively. Descriptive analysis was used to explore the respondents' characteristics and use of LAPM on a self-weighted samples. Univariable and multivariable binary logistic regression models using svy command were used to assess factors associated with the use of LAPM. A total of 762 and 531 women for the baseline and end line survey, respectively were included in this study. The prevalence of use of LAPM for baseline and end line survey were 21.5% (95% CI: 18.7-24.6%) and 23.2% (95% CI: 19.6%-27.0%), p-value = 0.485. The use of LAPM in Kisii and Kilifi counties was higher than the national average in both surveys. The multivariable analysis for the end line survey showed having 3-5 number of children ever born (aOR = 2.04; 95% CI: 1.24-3.36) and future fertility preference to have another child (aOR = 0.50; 95% CI: 0.26-0.96) were significantly associated with odds of LAPM use. The baseline showed that having at least secondary education (aOR = 1.93; 95%CI: 1.04-3.60), joint decision making about woman's own health (aOR = 2.08; 95%CI: 1.36-3.17), and intention to have another child in future (aOR = 0.59; 95%CI: 0.40-0.89) were significantly associated with the use of LAPM. Future fertility preference to have another child was significantly associated with the use of LAPM in the two surveys. Continued health promotion and targeted media campaigns on the use of LAPM in rural areas with low socioeconomic status is needed in order to improve utilization of these methods. Programs involving men in decision making on partner's health including family planning in the rural areas should be encouraged.

Background

Long-acting reversible and permanent contraceptives are one of the most effective and economical family planning methods worldwide to due to its numerous health benefits of preventing unintended pregnancies, promoting healthy birth spacing, reducing lifetime risk of maternal deaths, and enhancing attainments of development goals such as education and gender equality [1]. The World Health Organization (WHO) recommends spacing births for at least 24 months between pregnancies to give a mother time to recover from previous pregnancy since shorter birth intervals are characterized by negative maternal, foetal, and infant health outcomes [2, 3]. The use of contraceptives among women of reproductive age in low- and middle-income countries (LMICs) is still low compared to high-income countries [4]. Regions with high fertility rates tend to have a low contraceptive prevalence rate (CPR) and sub-Saharan Africa (SSA) region is not exceptional [5]. The CPR is defined as percentage of married or in-union women aged 15–49 years who are currently using, or whose sexual partner is currently using, at least a method of contraception.

Globally, there was an increase in CPR from 42% [6] in 1990 to 49% [7] in 2019 among women of reproductive age. In SSA, the CPR had increased from 13% to 33% between 1990 and 2020 [8], in Oceanic, from 20% to 28%; in Northern Africa and western Asia, from 26% to 34%, in central and southern Asia from 30% to 42% and in Latin America and the Caribbean from 40% to 58% [6]. In Kenya, the CPR increased from 33% in 1993 to 58% in 2014 [9]. Kenyan CPR in 2014 was lower than Rwanda (64.1%) in 2019, but higher than in neighbouring countries such as Burundi(28.5%) in 2016,Ethiopia (41.4%) in 2019, Tanzania (38.4%) in 2015, and Uganda (39.0%) in 2016 [9].

Family planning is a highly cost-effective intervention in Kenya with a healthcare cost saving of US $4.48 for every US $1 spent [10] and is one of the prioritized population and development programs [11]. In 1982, the National Council for Population and Development (NCPD) was established to “coordinate the implementation of population and development activities in Kenya,” including mobilising political and financial support for population, family planning and reproductive health policies and programmes [12]. In addition, Kenya committed to the FP2020 goals to improve access to family planning services in order to increase modern CPR (mCPR) to 66% by 2030, adolescent women CPR to 55% by 2025 and to reduce teenage pregnancy from 18% to 10% by 2025 [13]. With these mechanisms to promote family planning programs, Kenya increased the CPR among married women from 7% in 1978 to 33% in 1993, 58% in 2014 [14], and 62.8% in 2019 in selected regions of the country [15].

Women can choose from a wide range of contraceptives, which include short-acting or long-acting reversible contraceptives (LARC) or permanent methods [16]. Most Kenyan women uses short-acting reversible contraceptives mainly injectables and pills, which have high discontinuation or switching rates compared to intrauterine contraceptive devices (IUCD) and implants [14, 17]. The high discontinuation rate of short-acting methods could be due to switching to more effective methods, contraceptive method stock-outs, prefer to conceive or fear of side effects associated with a particular method [14]. Contraceptive discontinuation among women with unmet need of contraception exposes a woman to the risk of unintended pregnancy and induced abortions [18, 19]. Promoting the use of long-acting reversible and permanent methods (Intra-Uterine Devices (IUDs), Implants, Tubal ligation, female sterilization and Vasectomy) with low discontinuation rate could be beneficial to many of these women.

The 2014 Kenya demographic and health survey (DHS) estimated that only 9.9%, 3.4%, 3.2%, and 0.0% of married couples used implants, IUCD, female sterilization, and vasectomy, respectively [14]. The low national prevalence could be attributed to the availability and access of these methods as suggested by the proportion of health facilities in Kenya offering IUCD, implants, female, and male sterilization to be 75%, 58%, 7%, and 5%, respectively [20], or other factor related reason, opposition to use, lack of knowledge, and method related reasons; lack of trained providers and wide availability of short-acting methods in the rural areas [21]. Previous studies associated the use of LAPM with the number of living children [22, 23], having three or more children [22, 24–27], area of residence [22], region [22, 28, 29], woman’s age [22, 23, 28, 29], education levels [23, 27, 28, 30–32], wealth status [23–25, 28, 31], joint decision making on family planning use with partner [33, 34], no desire for more children [30], and level of knowledge on LAPMs [26, 32]. While determinants of LAPM have been documents in several programs implemented in diverse settings to promote utilization, there remain a need to understand prevalence and determinants in the rural Kenyan context. Therefore, the study aimed to determine the prevalence and factors associated with the current use of long acting (Implant and IUCD) and permanent (Vasectomy and female sterilization)contraceptive methods among married women of reproductive age (15–49 years) in rural Kenya based on a community study in targeted areas of Kisii and Kilifi counties.

Methods

Data source, setting, and population

The study used data from the baseline and end-line survey of the AQCESS project, conducted between August and September 2016 and January and February 2020, respectively in four rural targeted implementation sub-counties of Kisii and Kilifi counties. The AQCESS project aimed to contribute to the reduction of maternal and under-five mortalities in Kenya; its organization and implementation have been described in our previous papers [35, 36]. The project promoted the use of family planning through community sensitisation messages by the community health volunteers (CHVs) as one of the implementation activities, however, there was no family planning commodity provided by the project during the implementation period. Details of design and conduct of baseline survey is discussed in our previous paper [35]; the below sections described the design and conduct of the end line survey.

The repeat cross-sectional survey was conducted in Kaloleni and Rabai sub-counties in Kilifi County and Bomachoge Borabu sub-county in Kisii County with a population of 304,778 and 129,617, respectively [36]. The maternal mortality rate in Kilifi was 448 deaths per 100,000 live births, and an under-five mortality rate of 87 deaths per 1,000 live births [36], with 70% of the population living below the poverty line. Under-five mortality rates in Kisii County was 36 deaths per 100,000 live births, however only 44% of its population living below the poverty line. Both counties have a high teenage pregnancy rate (Kisii 18.4% and Kilifi 21.8%) [36], which is higher than the national average of 18% [14, 36]. Kaloleni and Rabai sub-counties are served by 40 health facilities, while Bomachoge Borabu County is served by 12 health facilities [36]. About 82% and 93% of health facilities in Kilifi and Kisii offer family planning (FP) services; 49% and 93% of which offer services to adolescents, respectively. The CPR for the regions in 2014 were 34.1% and 66.1% for Kilifi and Kisii counties [20]. There are numerous structural challenges, including limited human healthcare resources, poor access to health services due to geographical and transportation barriers, and limited healthcare infrastructure, including a high physician and nurse to population ratio in these counties [36].

The survey employed a two-stage sampling procedure considering a village as a cluster: In the first stage of sampling, a selection of 30 villages in each of the two sites were selected based on probability proportional to the number of households in each village. The second stage involved a random selection of households from a master frame of the household listing in the selected villages. The household listings were provided by the village elders who were familiar with the village boundaries. No further sampling was carried at the selected household level. All assented and consented women aged 15–49 years old and permanent residents of the selected villages were included in the survey.

The minimum sample size of 1788 households was calculated for the survey based on the following assumptions: an expected increase in the contraceptive prevalence rate between the baseline (2016) and end-line (2020) periods of 10%; 80% as the power; 95% level of significance; design effect of two; and a 20% non-response rate to account for absent household members during data collection. Figs 1 and 2 highlights the final study sample size for endline and baseline respectively after excluding women who were pregnant, unmarried, last menstruated more than six months before the survey, menopausal, never menstruated, did not know their last date of menstruation period, and those who preferred not to answer.

Fig 1

The population of the women aged 15–49 years included and excluded in the endline analysis.

Fig 2

The population of the women aged 15–49 years included and excluded in the baseline analysis.

Data collection tool and procedures

Trained enumerators collected data using tablets pre-installed with a standardized electronic questionnaire programmed on the Open Data Kit (ODK) software in English and the local languages of the study areas (Giriama, Ekegusi, and Swahili). The questionnaire adapted questions from the Demographic and Health Surveys and Multiple Indicator Cluster Surveys to allow for comparison. The questionnaire was pretested in the nearby villages which were not part of the actual survey before the start of the actual survey. Each supervisor was assigned team of six enumerators to manage; the supervisor ensured that the sampled households were interviewed and repeat visits conducted to absent household members conducted. After three unsuccessful repeat visits, a household was considered to have absent members for the duration of the survey. The collected data were synchronized into a secure, password-protected cloud-based server, allowing for real-time data quality assurance. Other quality checks performed during data collection included random spot-checks, close supervision of the enumerators, routine data cleaning, and addressing all identified issues prior to the start of data collection on any given day.

Measures

The main outcome variable was LAPM use, which was assessed based on two questions: (i) “Are you or your partner currently doing something or using any method to delay or avoid getting pregnant?” and (ii) “What are you currently doing to delay or avoid pregnancy?”. Based on responses to the question (ii), women were classified as LAPM user (intrauterine contraceptive devices, implants, and male and female sterilization) or otherwise a non-user of LAPM. The non-users of LAPM includes users of short-acting/traditional methods (emergency contraception, injectable, male condoms, oral contraceptive pills, and traditional FP methods) and non-users of any method of contraceptive. Specifically the main outcome was binary in nature defined as:

Where Y, is the response for the ith individual woman.

Independent variables were identified based on a review of literature of previous studies on LAPM [19, 30, 31, 37–44] and included age measured in completed years at the time of the interview categorized into age groups (15–19, 20–29, 30–39, and 40–49 years); level of education (none, primary, and secondary and above), household wealth tercile (poor, middle, and rich), future fertility preference (no more/none and have ((an)other) child(ren), number of children ever born (CEB) as at the time of the survey (0–2, 3–5 and 6 or more), exposure to media was classified as yes for those who had listened to radio or watched television or read newspaper or accessed social media at least once a week and no for those who had not [23] and the main decision-maker on a woman’s health (woman alone, woman with a partner, and other). The other decision-makers included the husband/partner alone, father or father-in-law, mother or mother-in-law, other male family members, and other female family members. Household wealth terciles were generated based on a wealth score computed using the principal component analysis approach using household assets and materials for the dwelling floor, roof, and external wall [45]. Variables on exposure to media and number of children ever born were not collected during the baseline survey.

Statistical analysis

Data were explored descriptively using the median and interquartile range (IQR) for continuous variables and frequencies and percentages for categorical variables. Chi-square test was used to compare the difference between the categorical groups. The multivariable logistic model was used to assess the factors associated with the use of LAPM while controlling for other variables. All the variable were considered to be important in explaining the outcome and were adjusted for in the multivariable logistic regression. The crude (cOR) and adjusted odds ratio (aOR) with the 95% confidence interval (CI) for the estimates is reported, and a p-value of less than 0.05 was considered statistically significant. We used “svy” set command in Stata to account for clustering due to complex sampling design of the study at village level. All analysis were conducted in Stata (15, StataCorp LLC, College Station, TX).

Ethics

The study was approved by the Aga Khan University Institutional Ethics Review Committee and research permit provided by the National Commission for Science, Technology, and Innovation. County approvals were obtained from the Ministries of Health in Kisii and Kilifi Counties. Written informed consent were obtained from each participant before the start of data collection, with those who could not write providing consent using their thumbprint. Women aged 15–17 years old provided assent and additional consent from their parents/guardians or whoever they were comfortable with consenting on their behalf. The survey was conducted in line with the Helsinki Declaration on Research involving Human Subjects.

Results

Socio-demographic characteristics

Overall, 762 and 531 women were included in the baseline and end-line analysis, respectively. Majority of participants at baseline and endline were 30–39 years, poor, had completed primary school, and did not have or want more children (Table 1). In addition, at the end-line, more than two-thirds of the participants had been exposed to information on family planning in the media and majority had 3–5 children (Table 1). LAPM was used by 164 (21.5%), short-acting/traditional by 322 (42.3%) and 276 (36.2%) were not using any contraceptive during the baseline survey. In the endline survey, 123 (23.2%), 228 (42.9%), and 180 (33.9%) were using LAPM, short-acting/traditional and non-users respectively (Table 1).

Table 1

Participants’ characteristics stratified by county of residence at baseline and end line.

	Baseline			End line
		County of residence			County of residence
Variable	Overall	Kilifi,	Kisii,	Overall	Kilifi,	Kisii,
	N = 762	N = 409 (53.7%)	N = 352 (49.2%)	N = 531	N = 292 (55%)	N = 239 (45%)
Age, years, Median (IQR)	31 (26–38)	32 (26–38)	30 (26–37)	32 (26–38)	32 (26–37)	33 (27–38)
Age-group, years, n (%)
15–19	25 (3.3)	14 (3.4)	11 (3.1)	20 (3.8)	7 (2.4)	13 (5.4)
20–29	292 (38.3)	147 (35.9)	145 (41.1)	182 (34.3)	111 (38)	71 (29.7)
30–39	296 (38.8)	164 (40.1)	132 (37.4)	223 (42.0)	115 (39.4)	108 (45.2)
40–49	149 (19.6)	84 (20.5)	65 (18.4)	106 (20.0)	59 (20.2)	47 (19.7)
Level of education, n (%)
None	131 (17.2)	125 (30.6)	6 (1.7)	79 (14.9)	79 (27.1)	0 (0.0)
Primary	420 (55.1)	249 (60.9)	171 (48.4)	274 (51.6)	168 (57.5)	106 (44.4)
Secondary+	211 (27.7)	35 (8.6)	176 (49.9)	178 (33.5)	45 (15.4)	133 (55.6)
Wealth tercile, n (%)
Poor	492 (64.6)	309 (75.6)	183 (51.8)	428 (80.6)	238 (81.5)	190 (79.5)
Middle	143 (18.8)	69 (16.9)	74 (21.0)	72 (13.6)	39 (13.4)	33 (13.8)
Rich	127 (16.7)	31 (7.6)	96 (27.2)	31 (5.8)	15 (5.1)	16 (6.7)
Decision-making about own health, n (%)
Woman alone	185 (24.3)	90 (22.0)	95 (26.9)	159 (29.9)	70 (24.0)	89 (37.2)
Other members*	365 (47.9)	233 (57.0)	132 (37.4)	123 (23.2)	66 (22.6)	57 (23.8)
Women jointly with partner	212 (27.8)	86 (21.0)	126 (35.7)	249 (46.9)	156 (53.4)	93 (38.9)
Future fertility preference, n (%)
No more/none	411 (53.9)	176 (43.0)	235 (66.6)	274 (51.6)	112 (38.4)	162 (67.8)
Have ((an) other) child(ren)	351 (46.1)	233 (57.0)	118 (33.4)	257 (48.4)	180 (61.6)	77 (32.2)
Exposure to media, n (%) †
Yes				364 (68.5)	180 (61.6)	184 (77.0)
No				167 (31.5)	112 (38.4)	55 (23.0)
Number of children ever born n (%) †
0–2				211 (39.7)	109 (37.3)	102 (42.7)
3–5				234 (44.1)	129 (44.2)	105 (43.9)
6 or more				86 (16.2)	54 (18.5)	32 (13.4)
Current use of contraceptives, n (%)
LAPMs	164 (21.5)	93 (22.7)	71 (20.1)	123 (23.2)	55 (18.8)	68 (28.5)
Short/traditional	322 (42.3)	144 (35.2)	178 (50.4)	228 (42.9)	119 (40.8)	109 (45.6)
None	276 (36.2)	172 (42.1)	104 (29.5)	180 (33.9)	118 (40.4)	62 (25.9)

†Data not collected during the baseline survey

* others included: husband/partner alone; mother or mother-in-law; other female family member

Prevalence of LAPM use

The prevalence of LAPM use were 21.5% (18.7%-24.6%) and 23.2% (95% CI: 19.6%–27.0%), p-value = 0.485 for the baseline and end line survey, respectively. Among the LAPM users during the endline, 24.5% used implants followed by female sterilization (7.1%), IUCD (2.8%) and male sterilization (0.6%). The use of these methods were slightly higher compared to the baseline (Fig 3). The proportion of women using LAPM was relatively high in Kisii County (55.3%) during the end line survey compared to baseline (43.3%). In the end line survey, LAPM prevalence was high among women were 30–39 years (44.7%), with primary level of education (49.6%), with 3–5 children (56.9%), and from the poor wealth tercile (77.2%) (Table 2). There was no significant difference in proportion in LAPM use between baseline and end line survey for different variables except in county of residence (p-value = 0.044), secondary and above level of education (p-value = 0.015), poor (p-value = 0.007) and rich (p-value = 0.018) wealth tercile, and decision making about own health with other family members (p-value = 0.035). (Table 2).

Fig 3

Types of contraceptive current used by woman or husband/partner and prevalence of LAPM (baseline: N = 762 and endline: N = 531).

Table 2

Prevalence of contraceptive use according to participants’ characteristics at baseline and end line survey.

Variable	Baseline			End line			The difference in LAPM use between baseline and endline, p-value
	LAPM, N = 164 (21.5%)1	Short/ traditional, N = 322 (42.3%)1	None, N = 276 (32.2%)1	LAPM, N = 123 (23.2%)1	Short/ traditional, N = 228 (42.9%)1	None, N = 180 (33.9%)1
County of residence, n (%)
Kilifi	93 (56.7)	144 (44.7)	172 (62.3)	55 (44.7)	119 (52.2)	118 (65.6)	0.044
Kisii	71 (43.3)	178 (55.3)	104 (37.7)	68 (55.3)	109 (47.8)	62 (34.3)	0.044
Age, years, Median (IQR)	30 (26–35)	30 (25–36)	34 (26–42)	30 (26–35)	32 (26–37)	33 (28–41)
Age-group, years, n (%)
15–19	5 (3.0)	11 (3.4)	9 (3.3)	2 (1.6)	10 (4.4)	8 (4.4)	0.439
20–29	65 (39.6)	135 (41.9)	92 (33.3)	50 (40.7)	80 (35.1)	52 (28.9)	0.862
30–39	73 (44.5)	132 (41.0)	91 (33.0)	55 (44.7)	100 (43.9)	68 (37.8)	0.973
40–49	21 (12.8)	44 (13.7)	84 (30.4)	16 (13.0)	38 (16.7)	52 (28.9)	0.959
Level of education, n (%)
None	21 (12.8)	35 (10.9)	75 (27.2)	9 (7.3)	30 (13.2)	40 (22.2)	0.133
Primary	95 (57.9)	184 (57.1)	141 (51.1)	61 (49.6)	129 (56.6)	84 (46.7)	0.161
Secondary+	48 (29.3)	103 (32.0)	60 (21.7)	53 (43.1)	69 (30.3)	56 (31.1)	0.015
Wealth tercile, n (%)
Poor	102(62.2)	203 (63.0)	187 (67.8)	95 (77.2)	192 (84.2)	141 (78.3)	0.007
Middle	31 (18.9)	66 (20.5)	46 (16.7)	17 (13.8)	31 (13.6)	24 (13.3)	0.254
Rich	31 (18.9)	53 (16.5)	43 (15.6)	11 (8.9)	5 (2.2)	15 (8.3)	0.018
Decision-making about own health, n (%)
Woman alone	34 (20.7)	83 (25.8)	68 (24.6)	35 (28.5)	62 (39.0)	62 (39.0)	0.130
Other family members*	62 (37.8)	154 (47.8)	149 (54.0)	32 (26.0)	52 (42.3)	39 (31.7)	0.035
Women jointly with partner	68 (41.5)	85 (26.4)	59 (21.4)	56 (45.5)	114 (45.8)	79 (31.7)	0.127
Future fertility preference, n (%)
No more/none	95 (57.9)	170 (52.8)	146 (52.9)	75 (61.0)	111 (48.7)	88 (48.9)	0.603
Have ((an) other) child(ren)	69 (42.1)	152 (47.2)	130 (47.1)	48 (39.0)	117 (51.3)	92 (51.1)
Exposure to media, n (%)
Yes				94 (76.4)	164 (71.9)	106 (58.9)
No				29 (23.6)	64 (28.1)	74 (41.1)
Number of children ever-born, n (%)
0–2				40 (32.5)	94 (41.2)	77 (42.8)
3–5				70 (56.9)	102 (44.7)	62 (34.4)
6 or more				13 (10.6)	32 (14.0)	41 (22.8)

Bold: Statistically significant at p < 0.05

Factors associated with the use of LAPM

In the baseline survey, county of residence, decision-making on own health, future fertility preference, and level of education were significantly associated with the use of LAPM. The odds of LAPM use were 51% less likely for women in Kisii compared to those in Kilifi (aOR: 0.49, 95% CI: 0.31–0.77) and were twice high likely for those women who jointly made decisions on their health with their partners compared to those who made decisions alone (aOR 2.08, 95% CI: 1.36–3.17). Women who preferred to have another child in future were 41% less likely to use LAPM compared to those who do not want a child in future (aOR 0.59, 95% CI: 0.40–0.89). Women with secondary level of education were 1.93 time high likely to use LAPM compared to women with no formal education (aOR: 1.93; 95%CI: 1.04–3.60) (Table 3).

Table 3

Factors associated with the use of long-acting and permanent methods among women in rural areas, baseline (2016) and end line (2020) survey, Kenya.

Variables	Baseline		End line
	aOR (95% CI)	p-value	aOR (95% CI)	p-value
County of residence
Kisii	0.49 (0.31–0.77)	0.004	1.09 (0.55–2.16)	0.795
Age-group, years
20–29	1.00 (0.28–3.54)	0.997	2.64 (0.45–15.53)	0.263
30–39	0.92 (0.22–3.81)	0.905	1.36 (0.22–8.43)	0.725
40–49	0.40 (0.08–1.90)	0.235	0.68 (0.09–5.43)	0.702
Level of education
Primary	1.68 (0.94–2.98)	0.076	2.01 (0.62–6.50)	0.228
Secondary+	1.93 (1.04–3.60)	0.039	2.84 (0.68–11.83)	0.139
Wealth tercile
Middle income	1.02 (0.59–1.74)	0.144	0.86 (0.40–1.88)	0.696
Better income	1.31 (0.90–1.89)	0.949	1.68 (0.64–4.39)	0.272
Decision-making about own health
Women jointly with partner	2.08 (1.36–3.17)	0.002	1.14 (0.60–2.19)	0.671
Other members	0.83 (0.52–1.33)	0.423	1.28 (0.79–2.09)	0.299
Future fertility preference
Have ((an) other) children	0.59 (0.40–0.89)	0.013	0.50 (0.26–0.96)	0.040
Number of children ever born
3–5			2.04 (1.24–3.36)	0.008
6+			1.34 (0.51–3.51)	0.530
Exposure to media
Yes			1.39 (0.79–2.46)	0.233

aOR: adjusted odds ratio; CI: confidence interval; cOR: crude odds ratio; FP: family planning; IQR: interquartile range; LAPM: long-acting and permanent methods; Ref: reference category; significant factors in bold font.

In the endline, only future fertility preference and children ever born were significantly associated with LAPM use. Women with 3–5 children were two times more likely to utilize LAPM compared to those with 0–2 children(aOR 2.04, 95% CI: 1.24–3.36) whilst those who preferred another child in future had 50% reduced odds of LAPM use compared to those who did not have or want another child(aOR 0.50, 95% CI: 0.26–0.96) (Table 3).

Discussion

Slightly more than a third of married women in rural Kilifi and Kisii counties were using LAPM as at end line survey, which was higher than the national average of 28.5% [46], but was lower than the 57% of a community FP project in Western Kenya [47]. The improved use of contraceptives, including LAPM, could be attributed to ongoing efforts by the government and other health sector stakeholders towards promoting the uptake of modern contraceptive services in Kenya. The findings could also be attributed to the AQCESS project through community sensitisation messages by community health volunteers on the benefits of using family planning. The gains on the use of LAPM in these areas could be sustained by the government and non-governmental organisations aimed at addressing provider- and health system-related barriers such as low numbers of trained providers [48, 49], recurrent stock-outs, and fear of side effects [50].

Injectable which is a short-acting and reversible contraceptives are the most preferred methods in the two surveys. Short-acting methods tend to be readily available in most of the rural public health facilities [20] at a low cost [51]. Their use may be associated with women in their early childbearing ages and those who would not wish to delay their pregnancies for long period of time of their reproductive career [52]. The study found implants and female sterilization as the most commonly used LAPM compared to IUCD and male sterilization. The findings were supported by findings in other settings [53, 54]. Once inserted, implants can last for two to five years and can be easily removed without any delay in return to fertility [55]. The method is most available rural public facilities in Kenya than IUCDs, female and male sterilization [20, 56]. Male and female sterilizations are only offered in 5% and 7% of health facilities, respectively [20] and are not widely accepted, especially in the rural setting. The finding is similar to a study in Uganda that showed that low uptake of these methods were associated with poverty, limited awareness of the method, lack of skilled personnel to administer the method, and limited resources to purchase and maintain laparoscopic equipment [57]. Poor knowledge and information about the methods, along with religious and socio-cultural barriers, are some of the perceived barriers to the uptake of this method [58]. This emphasises the need for continued awareness and family planning educational sessions on modern family planning methods, including LAPM, to clients and providers.

Women with at least secondary level of education had higher odds of using LAPM compared to those with no formal education. The possible explanation could be that educated women have increased access to information on the side effects, benefits of using LAPM, and of smaller family size. Increased educational attainment especially secondary school and above influence service use of and female decision-making power on reproduction health issues particular family planning. The findings agrees with other studies conducted in Kenya, Ethiopia and Uganda that had shown that higher education is an important predictor of LAPM use [23, 59, 60].

Number of children ever born had a mixed relationship with the use of LAPM, women with children between 3–5 showed positive significant increase on the use of LAPM, but at higher number of children of 6 or more, there was a non-significant increase on the use of LAPM. This could be explained by the desire for women to have smaller family size and have decided to delay or limit future births LAPM; a method that offers long-term or permanent protection against unwanted pregnancies. This finding concurs with the finding of a study in Kenya and in Ethiopia [61, 62]. There are myths and misconception that these methods cause infertility which could be the reasons of low-use among women with 0–2 children. As the number of children increase fear of infertility related to those methods would decrease and women tend to use LAPMs [62]. On the other hand, women who wanted more children were less likely to use LAMP, which confirms the findings of a study in rural Kenya [30]. LAPMs offer efficient, long-term protection against pregnancy and women who may not have achieved their desired number of children may not prefer them as methods of choice [42].

Limitations

The study was limited in assessing the direct impact of the AQCESS project on the utilization of LAPM. The project was on maternal and child health program with little activities on family planning. The increase shown in the uptake between baseline and endline could be an effort of other stakeholders. Second, the study was conducted in targeted areas in the two counties, and hence may not be generalizable to the whole country. Third, contraceptive use was self-reported, which may have resulted in an underestimation or overestimation of the prevalence of contraceptive use. There were also other variables that could have influenced the uptake of the LAPM services such as husband approval of the use of LAPM, myths and beliefs on the methods which were not assessed with these surveys. Lastly, the two studies were cross-sectional, and causal relationships could not be established; only possible associations between the outcomes and the explanatory factors were studied.

Conclusion

About a third of married women in the study setting used LAPM, which is higher than the national average. The use of LAPM was associated with secondary and higher level of education, 3–5 number of children and future fertility preference. The study findings highlight a need for continued health promotion and media campaigns on family planning with a specific focus on the use of LAPM among women in rural areas and low socioeconomic status. Programs involving men in decision making about their health should be encouraged in these setting. Moreover, further research is needed to investigate the effects of other factors which were not studied in the current analysis, such as the use of media campaigns, training of health providers, equipping of health facilities, husband’s approval on the use of LAPM, and religious and socio-cultural barriers on the utilisation of LAPM.

English questionnaire for the survey.

(DOCX)

Click here for additional data file.

Anonymized dataset used in the analysis.

(CSV)

Click here for additional data file.

3 Feb 2022

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Zelalem T. Haile, PhD

Academic Editor

PLOS ONE

Journal Requirements:

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

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

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

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

3. Thank you for stating the following financial disclosure: "The funders had no role in  analysis, decision to publish, or preparation of the manuscript"

At this time, please address the following queries:

a) Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

b) State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

c) If any authors received a salary from any of your funders, please state which authors and which funders.

d) If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

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

"We are grateful to the Government of Canada, and the Aga Khan Foundation Canada for funding the end line survey from which data were extracted for this study. We acknowledge the Ministry of Health, and the  Kisii and Kilifi County governments, and the village elders, or support in conducting this study. We are grateful to participants who consented to the interviews and the AQCESS teams in Kenya (Kennedy Mulama, Rachel Odhiambo, Michaela Mantel, and Lucy Nyaga)."

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

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

"The funders had no role in  analysis, decision to publish, or preparation of the manuscript"

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

5. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

6. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

Additional Editor Comments (if provided):

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.

[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: Yes

Reviewer #2: Partly

**********

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: Yes

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: Reviewer Comments

Reviewer – Wambui Kungu (PhD Demography)

Manuscript No. PONE-D-21-23920

Title - Long-acting and permanent contraceptives use and associated factors among married women in rural Kenya: a community-based cross-sectional study

Overall Comments;

The article addresses an important topic on the use of long-acting and permanent contraceptives

among married women in rural Kenya and the associated factors. The topic is important in Kenya for several reasons;

i) The use of effective contraceptives is important for women to prevent unintended pregnancies that might pose serious health and social complications such as unsafe abortions and maternal/child morbidity and mortality. Women will able to attain more in education and economic status if they can get children when they want.

For the country, to reduce high costs incurred in maternal/child health care, unwanted fertility as well as the high population growth rate.

ii) Increased use of these contraception which are more effective will address the challenge of unmet need for contraception in Kenya which is high 22%. Kenya is currently putting interventions towards achieving zero unmet need for contraception in line with its ICPD25 country commitments made in 2019 at the Nairobi Summit of the International Conference on Population and Development 25th Anniversary.

iii) More use of these contraceptive methods will help reduce contraceptive discontinuation which is high at 31% and waters down the high contraceptive prevalence rate the country has attained.

iv) It addresses the issue of contraception among the poor and marginalized

Setting: This is important because it is rural and hence the need for more exposure to contraceptive information and services for the women.

Methodology

Data- The data is original, collection methods and quality controls reported are important for credibility. Quality assurance is given

Model – The GEE regression model is appropriate for the population based survey which was using clustered data

Sampling- The sampling gives focus to inclusivity to avoid bias. Numbers of women interviewed and the sampling procedures are adequate- Exclusion criteria reported is important. Fig 1 shows the issues.

Results- They are well presented in statistical language and discussed but improvements can be done on the presented information in the tables

References- They are recent, relevant and therefore appropriate

Recommendation – The paper is of publishable quality but needs some revisions and English language editing.

Specific Comments on areas that can be improved

Presented as -Line No- Issue for review- Suggestion

1-3 Title – add Kisii and Kilifi at the end- This will create more interest in the study

Long-acting and permanent contraceptives use and associated factors among married women in rural Kenya: a community-based cross-sectional study in Kisii and Kilifi Counties.

30 Use regression model instead of approach - equations regression model….

41 Insert the word rural after targeting- LAPM targeting rural women

45 Rewrite the sentence for clarity- Contraception helps to space and limit the number of children and thus prevents unintended pregnancies and unsafe abortions

46 Add sometimes because it is not always the case that health problems arise -intervals are sometimes characterized….

53-57 Rewrite the sentence to shorten it for clarity

Line 56 –add mCPR after CPR

Line 56-change contraceptive to contraception--modern CPR (mCPR)….- any method of contraception…..

60/61 Improve clarity- long-acting reversible contraception (LARC) or permanent methods

64 Add Citation besides [15]- I propose add citation of KDHS 2014 which presents discontinuation data

66-68 Can add a sentence on what the Government direction is to back up the information-Refer to the National Family Planning Costed Implementation Plan, 2017-2020

83 Addition to sentence -rural Kenya based on a community study in Kisii and Kilifi Counties.

87-88 Sentence improvement -The counties may not be called rural but the sub counties can be rural- February 2020 in four rural sub counties of Kisii and Kilifi Counties

97 Correction on the teen pregnancy rates -Kisii is 18.4 and Kilifi 21.8-Citation [23]- 18-22%

Add national average of 18% -Reference(KDHS,2014)

109-112 The sentence needs rewriting for more clarity -Especially add something on the issue of 80% power and 20% increase, design effect of two

181-183 Mention age of youngest and oldest also

189 Table 1 -Change word characteristic to Variable

Sample characteristic to Number/%

201 Figure 2 - Change word current to currently

202-203 Table 2

The bivariate and multivariate presentation can be improved to avoid congestion which is not friendly to a reader Change word characteristic to Variable

Word multivariate may be better than multivariable

Maybe subdivide each into two

cOR 95% CI

aOR 95% CI

207 Multivariable analysis-Word multivariate may sound better than multivariable

208 Rewriting - The odds of using LAPM were ……

213 Tense- have ever- Women who had given birth…..

214 Rewriting/tense odds of using LAPM compared to those who had…

217 Rewriting- add found in-lower than 57% found in a community FP

220 Rewriting- add modern -uptake of modern contraceptive services

223 Rewriting- add organizations-non-governmental organizations targeted…

224 Make plural - such as low numbers of trained providers

228 Cut sentence for clarity- at a low cost [36]. They may be

230 Improve clarity- And in conformity to previous studies

232 Improve clarity- remove when needed- easily removed without…..

233 Improve clarity- implants more than IUCDs [20, 40].

235 Remove our- in the study setting

240 Improve clarity- about the use of permanent methods because they are irreversible and provider hesitancy to remove LARCs [34].

241-243 Rewrite sentence for clarity

245 Improve clarity- higher odds of using LAPM among

247 Improve clarity- explain their higher use of implants

248-250 Improve clarity- The study also found that women in the richest wealth tercile were more likely to use LAPM than women in the poorest wealth tercile, which mirrors findings in other studies [44, 45].

255/256 Improve clarity- settings were rural with poor geographical accessibility to health facilities and with limited human healthcare resources

257 Add more - with 3–5 children were more likely to use LAPM

258-260 Rewrite sentence for clarity - LAPM offers efficient, long-term protection against pregnancy, and that these women may have achieved their desired number of children, or want to space their births.

260-261 Average children is 3.9 (KDHS,2014)- Improve clarity - Besides, Kenyan women have on average 3.9 children ever born [11], which is consistent with the study findings.

269 Improve clarity- only possible associations

274 Improve clarity- omit and-ever tercile, those who did not want more children and those had given birth to 3–5 children.

276-277 Rewrite sentence for clarity - LAPM among women in rural areas and low socioeconomic status. Moreover, further research is needed to investigate the effects of other factors which…..

References

327 KDHS year of publication- 2015

342 Ref 16 - i)Check authors names are written correctly - ii)DHS Analytical Studies 20

362 Ref 21- Complete Report No.

Reviewer #2: PONE-D-21-23920

Long-acting and permanent contraceptives use and associated factors among married women in rural Kenya: a community-based cross-sectional study

Thanks for the opportunity to review this manuscript. The paper discusses a very relevant topic in low- and middle-income countries (LMICs) where contraceptive use, especially use of LAPM remains poor despite many years of investment on family planning programmes. While millions of women across LMICs would like to space or limit their number of children, non-use of contraceptives remains high among them despite their sexual exposure and an expressed intention to avoid pregnancy. The authors use endline data from a health programme to assess prevalence and factors associated with the use of LAPM among married women in rural Kenya. I have some observations which if addressed would improve the paper.

TITLE:

LN 1-3: ‘Long-acting and permanent contraceptives use and associated factors among married women in rural Kenya: a community-based cross-sectional study’ Consider changing the title to ‘ Factors associated with use of long-acting and permanent methods among married women in rural Kenya: a community-based cross-sectional study’

ABSTRACT:

Include the sample size

BACKGROUND:

Generally, the background of this paper should be strengthened to make clear the new knowledge gap the study is filling. There are numerous studies on factors associated with use of LAPM including some from sub-Saharan Africa which authors should consider highlighting.

LN 46: Authors wrote ‘Shorter birth intervals are characterized by maternal, foetal, and

47 infant health problems’…There need to link this sentence with the first so that it is not left hanging. Also, consider replacing ‘health problems’ with’ negative health outcomes

LN 49: I would recommend to the authors to define what CPR means for readers not well versed in the field

LN 54: indicate the mandate of NCPD when it comes to FP?

METHODS:

The study is based on endline data from a program on improving Access to Quality Care and Extending and Strengthening Health Systems in Kilifi and Kisii counties of Kenya. Given that this programme also promoted FP, the results could be biased unless the analysis controlled for participation. There is need to describe efforts to address this particular bias. Alternatively, authors should consider using baseline data instead. Is it possible to indicate the number of participants who adopted a method including LAPM between baseline and endline?

Include a description of the study design under the method’s section. If cross-sectional, was it a repeated cross-sectional design?

The outcome variable ‘use of LAPM’ is dichotomous so logistic regression would be preferable.

It is not clear why the authors included ‘Heard about FP on social media’ as one of the independent variables. It appears superfluous as it does not have any influence in using LAPM relative to non-LAMP. It is so missing from the list of IV listed in LN140-150

RESULT:

Table 1- column 2, the percentage for each variable should add up to 100%

Ln 193: Authors wrote ‘The prevalence of LAPM use among women using contraceptives….’ Should read ‘The prevalence of LAPM use among married women using contraceptives… The result should be limited to only married women.

LN 194: Use of implants (24.5%) and female sterilization (7.1%) is more than double what was reported in the last KDHS. We need to see more in the discussion on what could be contributing to such a high increase in the study settings

LN 202: Table 2. It is interesting that some of the variables are insignificant on bivariate model but significant on the multivariate model. For example, age, future fertility preference and CEB. This is problematic and makes interpretation open to doubt. There could be confounding and collinearity issues that authors should address.

DISCUSSION:

LN 220-222, Authors wrote ‘The findings could also be attributed to the possible indirect effects of the AQCESS project through community activities that encouraged FP utilization’ As already mentioned above, the intervention could bias the findings, therefore there need to control for participation. What elements of FP did the AQCESS project promote Did it only focus on LAPM or other methods as well? If both, then we expect an increase in the use of both LAPM and non-LAPM methods.

LN 238-243: In addition to demand- and supply-side barriers mentioned, there is also provider-related bias which may influence contraceptive uptake. Partner/Husband’s approval of the methods also play a big role especially in patriarchal societies where men dominate everything including reproductive health decisions.

LN 245: Authors wrote ‘ The higher odds of LAPM use among younger women may be attributed to their need to avoid unintended pregnancies and optimize birth spacing compared to older women. I find it difficult to accept this given that on the bivariate model, the association between age and use of LAPM is not significant. Generally, we expect use of LAPM to increase by age.

OVERALL COMMENT:

The article should be checked for grammatical errors throughout

[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.]

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

Submitted filename: PONE-D-21-23920_Comments.docx

Click here for additional data file.

8 Apr 2022

see response to the reviewers attached with other documents

Submitted filename: Responses to Reviewers Comments.docx

Click here for additional data file.

2 Aug 2022

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Joseph Donlan, Senior Editor, on behalf of:

Bijaya Kumar Padhi, PhD, MPH

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: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

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

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

Reviewer #1: (No Response)

Reviewer #2: Partly

**********

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

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

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

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

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

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

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

Reviewer #1: (No Response)

Reviewer #2: No

**********

6. Review Comments to the Author

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

Reviewer #1: (No Response)

Reviewer #2: Thank you for the opportunity to review this manuscript for the second time. While the authors addressed some issues raised in the first draft, some still need attention, particularly on the methodology. See below my main comments:

General comments:

The articles have improved but need to be reviewed further for language and grammatical mistakes.

Introduction:

Line 46: What goals are you referring to here? Please indicate because the goals could be many.

Line 47: Insert the article 'The' before World and REPLACE 'World health organization' with 'World Health Organization. Also, add the acronym in the bracket, i.e., (WHO)

Line: 51-56: Authors wrote that 'Globally, regions with low fertility rates tend to have a high contraceptive prevalence rate (CPR) compared to sub-Saharan Africa (SSA), where the CPR is still low (5)'. Please add the CPR prevalence to show the magnitude of the variation you refer to. Compare CPR in the following order, global, regional, and national.

Line 68: indicate why we have a high discontinuation rate for injectables and Pill. I think discontinuation rates are high for the hormonal methods including implants, due to health-related reasons, including side effects and erroneous perception that some methods cause infertility.

Line 73: indicate which methods constitute the LAPM methods (i.e., Intra-Uterine Devices (IUDs), Implants, Tubal ligation, and Vasectomy) and why they have become a strategy for reducing maternal morbidity and mortality.

Methods:

Line 105-117: This paragraph highlights the context of the study, but it is heavy on MNCH indicators. Consider adding FP indicators that are already available from 2014 KDHS.

Measurement:

The study has some methodological biases that should be addressed. I still believe this study would add value by comparing the baseline and endline data sets, even though the design was not longitudinal. As already pointed out in the first draft, using endline data without controlling for women's participation in the project creates biases in the result since the AQCESS project promoted the use of family planning through community sensitization by the community health volunteers (CHVs). The authors assertion that family planning was not one of the critical interventions of the project is wrong since CHV sensitized women to FP. There is a possibility that some of the women were reached with FP messages; others may have not. In line 226, the authors allude to the effects of the AQCESS project on improving uptake of LAPM, but the analysis does not inform that.

While it is okay to exclude from the analysis menopausal women as well as those who had a hysterectomy, it is not clear why the analysis excluded non-users and pregnant women. Remember, non-use is also a choice women make regarding contraceptive use. One way of addressing this is to group the outcome variable into three categories: using long-acting and permanent contraceptive methods (IUD, female sterilization, and implant), using other methods (short-acting and traditional), and not using any method, and applying a multinomial logistic regression model instead of binary logistic.

In the flow diagram showing the analysis sample, it appears the study collected data on the timing the respondent started using LAPM. The timing a woman started using LAPM should be controlled for in the analysis. Such a variable could also assuage some of the weaknesses highlighted above.

Line 169: specify the confounders controlled for in the analysis

Line 166-173: Did the analysis control for the clustering effects? It is very important because of the survey design used.

Line 229-232: Authors argue that some supply-side factors are barriers to LAPM use, but I did not see that in the analysis result.

**********

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: Dr. Wambui Kungu

Reviewer #2: Yes: George Odwe

**********

[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.]

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

Submitted filename: comments to PONE-D-21-23920R1.docx

Click here for additional data file.

19 Sep 2022

The response to reviewer attached with the rest of the documents

Submitted filename: Reviewer.docx

Click here for additional data file.

21 Sep 2022

Factors associated with use of long-acting reversible and permanent contraceptives among married women in rural Kenya: a community-based cross-sectional study in Kisii and Kilifi counties

PONE-D-21-23920R2

Dear Dr. Orwa,

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.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

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

Kind regards,

Bijaya Kumar Padhi, PhD, MPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

22 Sep 2022

PONE-D-21-23920R2

Factors associated with use of long-acting reversible and permanent contraceptives among married women in rural Kenya: a community-based cross-sectional study in Kisii and Kilifi counties

Dear Dr. Orwa:

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.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Bijaya Kumar Padhi

Academic Editor

PLOS ONE