Women's decisions regarding family planning use and its determinants in Ethiopia: A systematic review and meta-analysis protocol.

BACKGROUND: Low use of contraceptives has many consequences. Despite this effect, less emphasis is given to women's decision-making on family planning use in Ethiopia. Although there are studies conducted in different parts of the country on women's decision-making regarding family planning use, there are inconsistent findings and a lack of national representative data. Thus, this systematic review and meta-analysis aimed to determine the pooled prevalence of women's decision-making regarding family planning use and its determinants in Ethiopia.
METHODS: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines will be followed to develop the review protocol. All observational studies will be retrieved using Medical Subject Heading (MeSH) terms or keywords from the online databases PubMed, CINAHL, Google Scholar, African Journal online, and gray literature. The quality of the studies will be critically assessed using the Joanna Briggs Institute checklist. Heterogeneity among studies will be examined using I-squared statistics. Funnel plots and Egger's test will be used to examine publication bias. The meta-analysis will be performed using STATA version 14 software. Statistical significance will be determined at 95% CI. DISCUSSION: Improving women's autonomy in decision-making on reproductive health services, including contraceptive use, has a substantial advantage. There are studies on women's decision-making in family planning use; however, there are inconsistent findings. Therefore, this review protocol aims to determine the pooled prevalence of women's decision-making regarding family planning use and its determinants in Ethiopia. The findings from this systematic review and meta-analysis will help inform policy makers to develop appropriate interventions to improve women's decision making regarding family planning use.

Introduction

Women’s decision-making power in family planning use is the ability of women to decide freely independently or argue with their husbands or partners about family planning needs and choices [1]. Family planning (FP) is an effort made by couples to limit or space the number of children using family planning methods [2]. Women’s decision-making on family planning use is associated with delayed marriage, access to accurate information, free discussions of family planning needs and choices with partners, members of the household, and the community, and independent decisions on fertility regulation, including increased health-seeking behavior to contraceptives [3, 4].

Increased women’s decision making regarding family planning provides benefits such as safeguarding the health and rights of women, reducing maternal and child mortality, avoiding unplanned pregnancy and induced abortion, reducing long-term fertility rates, and improving households’ economic status [4-7]. Women’s decisions on family planning use have numerous benefits for the family, in particular, and the community at large, including the ability to challenge and control at the interpersonal level, increase to make choices on family planning methods, challenge the existing norms and culture to effectively increase their well-being, increase awareness of women’s on the types of family planning methods and build their capacity to challenge [8-11]. Women in low-income countries have been deprived of their reproductive health rights [6, 12]. The peculiar factors that predispose women in Africa to deprivation of reproductive rights and their decision-making power during family planning can be social factors such as the low educational status of women and their partners; low level of a couple’s communication on family planning methods, young age; area of residency; poor knowledge; lack of information about family planning; economic factors including household wealth status; media exposure; affordable, accessible, and acceptable quality of sexual and reproductive health care services and cultural factors such as attitude towards family planning methods; and social influence by husbands and the community [13-16]. Contraceptive use was much lower due to the challenge of social, cultural, or economic factors, although women in developing countries, particularly in Africa, would like to delay or stop childbearing [4, 17, 18].

In developing countries, contraceptive use is low (40%), and approximately 225 million women have an unmet need for family planning methods [19]. In sub-Saharan Africa, contraceptive use varies from 6.7% in Chad and 72% in Namibia [3]. In Ethiopia, contraceptive use was low (41.4%), and 22% of women had an unmet need for family planning methods. This leads to a high total fertility rate (TFR) of 4.6 children per woman and contributes to maternal mortality 412 per 100,000 live births, neonatal mortality 30, infant mortality 43, and underfive mortality 55 per 1000 live births [20, 21].

Low utilization of contraceptive methods has many consequences, such as high common childhood illness, lack of appropriate health, poor maternal and child health care, increased maternal and child mortality, increased workload of mothers, poor child growth, and unfavorable impact on economic status and growth [2, 22–24]. Factors affecting women’s decision-making regarding family planning use were educational level, socioeconomic status, domestic decision-making position, male partner influence, lack of knowledge, gender-based inequalities, and low access to reproductive health services [22, 25–30]. Due to harmful, biased social norms and practices and a lack of financial resources, women are regularly incapable of accessing sexual and reproductive health services. Moreover, lack of access to services reduced women’s ability to make choices about their sexual and reproductive health [14].

In Ethiopia, although the national 20-year health sector transformation plan [12] and national guidelines for family planning services [2] emphasize women’s decision-making on family planning use, family planning use is still low, and there is a lack of nationally representative data on women’s decision-making on family planning use [20, 21]. There are studies conducted in different parts of the country on women’s decision-making in family planning use [22, 25, 31–35]; however, there are inconsistent findings, with a prevalence of women’s decisions regarding family planning use ranging from 35.9% to 98%. Moreover, inconsistent findings on factors affecting women’s decisions regarding family planning use were reported among the studies, including residence, knowledge, attitude, educational status, occupational status, age, income, husband influence, and number of living children. Women’s decision making regarding family planning will be considered whether women have decision-making power regarding delayed marriage, access to accurate information, free discussion about family planning needs and choices with partners, independent decisions on fertility regulation and increased health-seeking behavior to contraceptives in the primary studies. Thus, this systematic review and meta-analysis protocol aimed to determine the pooled prevalence of women’s decision-making regarding family planning use and its determinants in Ethiopia.

What is the pooled prevalence of women’s decisions regarding family planning use in Ethiopia?

What are the determinants of women’s decisions regarding family planning use in Ethiopia?

To determine the pooled prevalence of women’s decisions regarding family planning use in Ethiopia.

To identify determinants of women’s decisions regarding family planning use in Ethiopia.

Methods

Study protocol and reporting

The Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines [36] will be used to prepare the systematic review protocol. The PRISMA-P 2015 checklist will be used for the review report [37] (S1 File).

Eligibility criteria

All observational studies, including cross-sectional, case–control, cohort and gray literature, performed in Ethiopia will be included. Case reports, case series, and preprints will be excluded from the review; if studies address both quantitative and qualitative findings on women’s decision making in family planning use, we will only consider the quantitative results. Studies published in English alone will be included. There will not be a restriction on the publication date.

CoCoPop/PEO search guide

Condition

Women’s decisions regarding family planning use Context; Ethiopia.

Population

Women of reproductive age group (15–49 years).

Exposure

Exposure is a determinant that increases or decreases the likelihood of women’s decision-making in family planning use among reproductive-age women in Ethiopia. The determinants can be the educational status of partners, domestic decision-making position, male partner influence, lack of knowledge on contraceptives, gender-based inequalities, and access to reproductive health services.

Outcome

The primary outcome of the study will be the pooled prevalence of women’s decision making regarding family planning use. Women’s decision making regarding family planning was considered whether women have decision-making power regarding delayed birth spacing, access to accurate information, free discussion about family planning needs and choices with partners, independent decisions on fertility regulation and increased health-seeking behavior to contraceptives in the primary studies. The secondary outcome of the study will be to identify factors affecting women’s decision making regarding family plaining use. The selection of independent variables was based on how frequently the variables were reported in the primary studies, and factors that reported more than one study and had consistent classification were included.

Search strategy and study selection

PubMed, Google Scholar, African Journal Online, CINAHL and gray literature will be used to search studies. In addition, cross-references searching of related studies will be performed from the included studies. An independent search will be performed by two authors. The retrieved studies will be exported to Endnote version 8 reference manager to collect, organize and manage search results [38], and the studies will be screened independently by removing duplicate and irrelevant titles and abstracts. Full text selected studies will be evaluated further for quality. The process of article selection and report results will be reported using the PRISMA chart ( The Medical Subject Heading (MeSH) terms and entry terms will be used to search articles from databases. Then, Boolean operators (OR, AND) will be used to search studies from the online database (S3 File).

Quality assessments

The quality of studies will be assessed using their title, abstract, and full-text review before the inclusion of studies in the final systematic review and meta-analysis. The Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) will be used to assess the quality of the studies [39]. The tool emphasizes explicit inclusion and exclusion criteria, standard measurement criteria, study subjects and setting, strategies to deal with confounding, exposure measurement validly and reliably, outcome measurement, and appropriate statistical analysis (S4 File). The full-text articles will be assessed by two authors (EW and SB). A quality scale of 50% and above will be considered and included in the review. Disagreements among reviewers will be discussed by the third author (MA) to reach an agreement.

Data extraction and management

Independent piloting of the data extraction will be carried out in Microsoft Excel (2016) before the beginning of the actual data extraction. The data extraction tool will contain information on the first author name, publication year, study setting, study design, sample size, prevalence, odds ratio, lower and upper bounds of the confidence interval, log transformation, and standard error of logarithm. The actual data extraction will be performed by the two authors (EW and ZH). Discrepancies in data extraction will be resolved by discussion with a third author (MA). In case of missing data or incomplete reports, the corresponding authors of the studies will be contacted.

Data synthesis and analysis

Importing of extracted data to STATA version 14 for analysis will be performed. Tukey’s test. Freeman Tukey’s test will be used for square root transformation of data to avoid variance variability [40].

A random-effects model will be used to determine the pooled prevalence of women’s decision-making in family planning use in Ethiopia [41]. Forest plots will be used to present the pooled prevalence and determine women’s decision-making in family planning use at a p value of less than 0.05. 05 [42]. Cochran’s Q [43] and I2 statistics [44] will be used to identify heterogeneity across studies. The I2 statistic estimates the percentage of variation across studies. I2 values of 25%, 50%, and 75% are representative of low, moderate, and high heterogeneity, respectively. The sources of heterogeneity will be determined using subgroup analysis and meta-regression. Moreover, sensitivity analysis will be performed to investigate the effect size of a single study. A funnel plot will be used to check publication bias using visual observation [42], and an asymmetry of funnel plot indicates publication bias. Statistical Egger’s and Begg’s tests [45] will be performed to check publication bias, and a p value of < 0.05 will be used to declare publication bias.

Discussion

This systematic review and meta-analysis protocol aims to synthesize the pooled prevalence of women’s decisions regarding family planning use and its determinants in Ethiopia. Improving women’s autonomy in decision-making on reproductive health services, including contraceptive use, has substantial advantages, including fertility regulation, reduction of child mortality, and improvement of households’ child feeding practices [5, 6, 19, 34, 46–48].

Studies have shown that low contraceptive use leads to a lack of proper care for children from household members [24]. Worldwide, approximately six million children die before reaching their first year birthday, and approximately 35 women die every hour due to birth-related complications [49-51]. In developing countries, particularly sub-Saharan African countries, contraceptive utilization was low [23, 24]. In Ethiopia, contraceptive use was low, and there was a higher unmet need for family planning, total fertility rate, and neonatal, infant and maternal mortality [20, 21].

The findings from this systematic review and meta-analysis will help to identify the pooled prevalence and determinants of women’s decisions regarding family planning use and help to inform policy makers to develop appropriate interventions to improve women’s decisions regarding family planning use. This review protocol may have limitations, including heterogeneity due to differences in study designs, sample sizes, and publication biases. Articles published only in English will be included. Only observational study designs will be included, and interventional and quasiinterventional studies will be excluded from the review.

PRISMA-P 2015 checklist.

(DOC)

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Diagrammatic presentation of the study selection process for systematic review.

(DOCX)

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Database search terms.

(DOCX)

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JBI critical appraisals for observational studies link: https://jbi.global/critical-appraisal-tools.

(DOCX)

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23 Aug 2022

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Additional Editor Comments (if provided):

I have carefully reviewed the manuscript titled “Women’s decisions regarding family planning use and its determinants in Ethiopia: systematic review and meta-analysis protocol” and my comments are stated below:

General comment: This proposed study will address an important research question concerning family planning and women’s ability to make decision regarding this within the Ethiopian context. Hence, the study is relevant and warranted especially given challenges that women face in developing settings regarding reproductive health-related choices / decisions. However, I have identified a number of crucial gaps that will require adequate revision before the manuscript is ready for publication. The areas requiring revision are stated below. In addition, the manuscript will generally require professional language editing to improve grammar, syntax, clarity and sentence construction.

Abstract: Appeared relatively well written and focused on the stated aim. The proposed method and brief discussion of the expected results appeared appropriate for the stated aim.

Introduction: Appeared relatively well written but require professional English language editing. Furthermore, authors should address the following points during the revision of the manuscript:

• The review of the existing published body of knowledge in the research area seems inadequate and speculative in some areas. The depth of literature search and summarized discussion of the state of the art of published knowledge in the research area appeared scanty.

• Authors did not provide details of the specific inconsistencies contained in the published findings related to women’s decision-making about family planning and the use of contraceptives in Ethiopia.

• Line 75-77: Lack of details regarding how having greater decision-making power by women will result in the stated benefits.

• Line 77: Lack of details regarding the peculiar factors (social, cultural or economic) that predispose women in Africa to deprivation of reproductive rights? How does this affect their decision-making power during family planning discussions or choices?

• Line 78: Why is that? What factors underline this? Is this cultural or economic? What factors underline this? Is this linked to the lack of decision-making power for women concerning family planning?

• Line 89-92: How? Provide details of how these factors have affected women decision-making power regarding family planning.

• Line 97-99: What were the major findings of these studies? What are the inconsistencies in the data / findings generated from these studies? This is a crucial gap in the introduction section which will provide a solid justification for conducting your SR/MA.

• Line 110: Lack of clarity regarding the specific component / aspect of women's decision-making that will be focused of the SR/MA.

Methods and Discussion: Appropriate for the stated study objective. However, professional language editing is required for grammar, syntax and clarity.

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: No

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2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: No

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3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: No

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4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. 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

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Reviewer #1: No

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Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

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Reviewer #1: The manuscript is poorly presented and difficult to read and understand. Scientific language is lacking for terms used, research questions and objectives poorly explained, the methodology is difficult to understand and the discussion is lacking depth and coherence.

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25 Aug 2022

Dear, editor, and reviewer

Editor Comments

≠ Authors did not provide details of the specific inconsistencies contained in the published findings related to women’s decision-making about family planning and the use of contraceptives in Ethiopia.

�  Addressed line 107-113

≠ Line 75-77: Lack of details regarding how having greater decision-making power by women will result in the stated benefits.

�  Addressed line 73-76

≠ Line 77: Lack of details regarding the peculiar factors (social, cultural or economic) that predispose women in Africa to deprivation of reproductive rights? How does this affect their decision-making power during family planning discussions or choices?

�  Addressed line 77-84

≠Line 78: Why is that? What factors underline this? Is this cultural or economic? What factors underline this? Is this linked to the lack of decision-making power for women concerning family planning?

�  Addressed line 77-84

≠Line 89-92: How? Provide details of how these factors have affected women decision-making power regarding family planning.

�  Addressed line 99-102

≠ Line 97-99: What were the major findings of these studies? What are the inconsistencies in the data / findings generated from these studies? This is a crucial gap in the introduction section which will provide a solid justification for conducting your SR/MA.

�  Addressed line 109-113

≠ Line 110: Lack of clarity regarding the specific component / aspect of women's decision-making that will be focused of the SR/MA.

�  Addressed line 113-117

Reviewer comments

Reviewer #1: The manuscript is poorly presented and difficult to read and understand. Scientific language is lacking for terms used, research questions and objectives are poorly explained, the methodology is difficult to understand and the discussion is lacking depth and coherence.

�  Language edited. Revised Manuscript with Track Changes and the clean manuscript was uploaded on the online submission.

Submitted filename: Respons to reviewers.docx

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6 Sep 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'.

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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.

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Kind regards,

Kazeem Babatunde Yusuff

Academic Editor

PLOS ONE

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Please update your Cover Letter to indicate whether you wish to have the manuscript considered as a Study Protocol, and confirm that neither recruitment nor data collection have been completed.

Additional Editor Comments:

1. Kudos to the authors for revising the manuscript for grammar, syntax and clarity. However, few minor edits for grammar remain. Please, check the manuscript to identify the areas requiring minor revision for grammar.

2. The response provided by the authors did not address my previous comment regarding ≠ Line 75-77 in the previous manuscript: Lack of details regarding how having greater decision-making power by women will result in the stated benefits. The revision done in line 73-76 of the revised manuscript did not address the comments. Please, revise this section accordingly.

Addressed line 73-76.

3. The response provided by the authors in line 77-84 of the revised manuscript did not address my previous comment regarding ≠ Line 77: Lack of details regarding the peculiar factors (social, cultural or economic) that predispose women in Africa to deprivation of reproductive rights? How does this affect their decision-making power during family planning discussions or choices? Please, revise the manuscript accordingly.

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

Reviewers' comments:

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8 Sep 2022

Dear, editor, and reviewer

Editor Comments

≠ Please update your Cover Letter to indicate whether you wish to have the manuscript considered as a Study Protocol, and confirm that neither recruitment nor data collection have been completed.

�  Addressed and uploaded on the online submission “Cover letter” file

Additional Editor Comments

≠ 1. Kudos to the authors for revising the manuscript for grammar, syntax and clarity. However, few minor edits for grammar remain. Please, check the manuscript to identify the areas requiring minor revision for grammar

�  Checked and uploaded on the “revised manuscript with track changes” file

≠ 2. The response provided by the authors did not address my previous comment regarding ≠ Line 75-77 in the previous manuscript: Lack of details regarding how having greater decision-making power by women will result in the stated benefits. The revision done in line 73-76 of the revised manuscript did not address the comments. Please, revise this section accordingly.

Addressed line 73-76.

�  Addressed on line 73-78

≠3. The response provided by the authors in line 77-84 of the revised manuscript did not address my previous comment regarding ≠ Line 77: Lack of details regarding the peculiar factors (social, cultural or economic) that predispose women in Africa to deprivation of reproductive rights? How does this affect their decision-making power during family planning discussions or choices? Please, revise the manuscript accordingly.

�  Addressed on line 79-88

Reviewer comments

#1: [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.]

�  The link "View Attachments" does not appear

#2: 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.

�  As this is a protocol, there is no figure. Only supporting information’s are available and uploaded on the online submission.

Submitted filename: Respons to reviewers.docx

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14 Sep 2022

The manuscript is still filled with grammatical and syntax errors in several areas, and these errors must be addressed with professional editing. A few of the examples of errors are stated below:

Line 75: “increase to make choices”

Line 77: “increase awareness of women's subordination”

Line 81: “such as the low educational status of women and partners;;”

Line 83” “antennal care visits;;”

Line 85: “such us attitude of family planning methods;;”

Line 91-92” “In developing countries, contraceptive use was low (40%), and the unmet need for family planning was 225 million people [20].”

Line 93-94: “In Ethiopia, contraceptive use was low (41.4%), and there was a high unmet need for family planning use (22%).”

Line 98: “Low upconsumption‒consumption”

Line 104: “and reproductive health services”

Line 113-118: “Moreover, there are studies conducted in different parts of the country on women's decision-making in family planning [8, 25, 31-35]; however, there are inconsistent findings, with a prevalence of women’s decisions regarding family planning use ranging from 35.9% to 98%, and different factors affecting women’s decisions regarding family planning use were reported among the studies, including residence, knowledge, attitude, educational status, occupational status, age, income, husband influence, and number of living children.”

Line 180-183: “The primary outcome of the study was the pooled prevalence of women’s decision making regarding family planning use. Women’s decision making regarding family planning was considered whether women have decision-making power regarding delayed marriage”

Line 185-186: “The secondary outcome of the study was to identify determinates of women’s decision making regarding family planning use”

Line 192-193: “online databases and gray literature will be used to search studies.”

Line 194-195: “Independent search strategies will be performed by (EW and SB).”

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