Understanding of middle east women’s decisions and barriers to use family planning methods

Hawraa Hussein Ghafel

doi:10.12688/f1000research.154232.1

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Research Article

Understanding of middle east women’s decisions and barriers to use family planning methods

[version 1; peer review: 3 not approved]

Hawraa Hussein Ghafel

PUBLISHED 06 Aug 2024

Author details Author details

Doctor in Maternal and Neonate Nursing Department, College of Nursing, University of Baghdad, Bab Al-Mua’adham, Baghdad City, 10011, Iraq

Hawraa Hussein Ghafel
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

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REVIEWER STATUS

Abstract

Background

when family planning methods not use, there is a higher chance of high fertility, which raises health risks for both mother and infant and lowers quality of life by limiting access to jobs employment, education, and nutrition. Unsatisfactory needs and poor family planning use can be explained by fear of negative impacts, rejection from couples, limits in knowledge, and social condemnation.

Objectives

To understanding the Middle East women’s barriers about make decisions and use of family planning methods

Methodology

A descriptive and analytic (cross sectional) study, conducted at six Arabic countries includes a non-probability (purposive sample) consist of (198) women. Which were selected according to inclusion criteria that are women in reproductive age, primiparous and multiparous mothers, and mothers who attended primary healthcare centers.

Results

Women are with average age of 32.23±7.9 years in which the highest percentage is seen with age group of 30-39 (40.4%). women have high affective barrier to avoid family planning methods (total grand mean= 2.60); have high behavioral barriers to avoid family planning methods (total grand mean= 2.56); and have high cognitive barriers to avoid family planning methods (total grand mean= 2.56). So, the mean scores indicate high among most of affective, behavioral, and cognitive barriers.

Conclusions

There are many potential barriers which can negatively impact the Middle East women’s decision about their reproductive life (affective, behavioral and cognitive) barriers. Despite the fact that family planning faces several challenges in the Middle East, governments and civil society organizations are working to find solutions to improve access to family planning services, promote education, hold candid conversations about reproductive health with local communities. Empowering the role of nurse in family planning to educate the couples about contraceptive methods and how to help them to choice the appropriate method.

Keywords

Middle East, Women’s Decisions, barriers, Family planning methods

Corresponding author: Hawraa Hussein Ghafel

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2024 Ghafel HH. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Ghafel HH. Understanding of middle east women’s decisions and barriers to use family planning methods [version 1; peer review: 3 not approved]. F1000Research 2024, 13:898 (https://doi.org/10.12688/f1000research.154232.1) First published: 06 Aug 2024, 13:898 (https://doi.org/10.12688/f1000research.154232.1) Latest published: 16 Jul 2025, 13:898 (https://doi.org/10.12688/f1000research.154232.2)

Introduction

Family planning can hasten a nation’s efforts to end poverty and realize its developmental objectives. Universal access to family planning and other reproductive health treatments is recognized as one of the most important objectives of the Millennium Development Goals (MDGs) of the United Nations.¹^–³

The high fertility that results from not using family planning methods also raises the risks of health problems for the mother and infant, which lowers quality of life and limits access to jobs employment, education, and nutrition. Family planning methods can be very important for population dynamics, which aid in the nation’s economic stabilization and enable it get over the challenges posed by faster population growth. Unsatisfactory needs and poor family planning use can be explained by fear of negative impacts, rejection from couples, decrease knowledge, and social condemnation. Cultural variations have also been mentioned as having an impact on the use of family planning, particularly with regard to conventional expectations and aspirations for more children and lines. Access to safe abortion services and contraception methods is correlated with low incidence of unwanted pregnancy. After women choose which method.⁴The ability of women to make freely chosen decisions on family planning needs and options, or to disagree with their husbands or partners on these matters, is known as women’s decision-making power in family planning. Couples that use family planning (FP) try to limit the number of children they have. Women make decisions about family planning use based on a variety of factors, such as delaying marriage, having access to reliable information, having open discussions about family planning options and needs with partners, family members, and the community, and making their own decisions about controlling their fertility, including using family planning methods more frequently.⁵

Family planning lowers maternal mortality and morbidity and helps prevent unintended pregnancies. Compared to other nations in the Eastern Mediterranean Region, Iraq still has a comparatively low prevalence of contraception (58%), and the country’s overall fertility rate (4.2 children per woman) and unmet requirement percentages (12%) are still rather high. Many public and commercial health facilities offer free or significantly subsidized services, but social, cultural, economic, or health care service limits may prevent many women from using them.⁶

Both men and women can plan their family sizes and prevent unwanted pregnancies, which not only increase maternal mortality but can also cause distress and anxiety. Reliable contraception makes this possible. Women in the Gaza Strip, Palestine facing challenges in using contraceptives, including user and viewpoints of the providers. Family planning services were not expected because most Palestinian women who visited the clinic had already chosen their method of birth control, with decisions being made by their husbands.⁷^–⁹ The primary motivation to improved access and support for women in the Middle East must be the experience growing up in the region and seeing firsthand the challenges and barriers women have when trying to obtain family planning. Challenges that impede the Middle East’s ability to get family planning services advancement in reaching family planning objectives, which exacerbates the region’s problems with gender equality and economic mobility. Prioritizing should be given to a number of important areas, such as lack of comprehensive education, healthcare infrastructure, economic restraints, religious influences, and stigma.¹⁰^–¹²

In the Arab world, balancing population growth, social and economic development, and environmental resources will also be aided by reducing unmet demand. Of all the regions in the world, the Middle East and North Africa region has the worst freshwater deficit.¹³^,¹⁴An analysis of Egypt’s 2008 DHS demonstrates that Egypt’s total fertility rate the number of births per woman during her lifetime would drop from 3.0 to 1. If women were able to successfully avoid having children as a result of unwanted pregnancies. 2.4 Unplanned pregnancies account for 14% of pregnancies in Egypt.¹⁵^,¹⁶

In nations where the rate of unwanted pregnancies is higher, the effect of lowering it on fertility would be even more pronounced. According to a research by the Higher Population Council of Jordan, if Jordan’s unmet family planning requirement had been decreased to half in 2009, that year’s total number of unplanned births would have been decreased by 10,000, or 6% of all births.¹⁷Compared to other wealthy nations, Saudi Arabia has a higher birth rate and overall fertility rate, and research has shown a correlation between these high rates and underdevelopment. Due to the swift expansion of the Saudi Arabian economy, there is a growing demand for the use of contraception and birth spacing.¹⁸^–²¹

In Lebanon, the overall count of births and cesarean sections is increasing.²² In Lebanon, the overall count of births and cesarean sections is increasing. There were 34 infant deaths for every 1000 live births, along with 23 births and 7 deaths per 1000 people. The population was rising at a pace of 1.6% per year, which was among the lowest in the Arab world. The 2.3 births were made by the average woman during her reproductive lifetime.²³

Unwanted births worldwide approximately 82% are caused by women who wish to prevent getting pregnant but are not utilizing an effective form of contraception.²⁴ The Arab world has a high rate of unwanted pregnancies, which burdens people, families, healthcare systems, and social and economic advancement.²⁵ A person’s ability to choose the quantity, timing, and spacing of their offspring is essential to preserving their reproductive rights. As described in numerous international agreements and human rights documents, reproductive rights stem from the fundamental rights to reproductive autonomy for all persons and couples, free from violence, compulsion, or discrimination. They cover rights related to getting married, starting a family, having children in a healthful manner, and being protected from HIV and other STDs.²⁶

Methods

Study setting

A descriptive and analytic (cross sectional) study, was conducted at primary health care centers in a six Arabic countries includes (Iraq, Lebanon, Jordan, Yamane, Egypt, and Saudi Arabia).women who were attending clinics for routine appointments and who met the inclusion criteria were requested to answer the questionnaire that was designed in a Google Form, and the questionnaire link was sent to them.

Study population

Non probability (purposive sample) consist of (198) women, which were selected according to inclusion criteria that are women in reproductive age, primiparous and multiparous mothers, and mothers who attended primary healthcare centers. The mothers provided informed consent and agreed to participate.

Sample size, sampling technique

The study sample size was calculated with a confidence interval of 85%, a population of 30 million women in reproductive age (defined as ages 15 to 49) in the six Arab countries that included in the study, and a 5% margin of error. The sample size was calculated as 208 using OpenEpi (Open Source Epidemiologic Statistics for Public Health).²⁷

A total of 208 mothers were included; however, 10 withdrew. The data of 198 participants were statistically analyzed. The inclusion criteria were mothers in reproductive age, primiparous and multiparous mothers, and mothers who visited primary healthcare centers. Samples were collected online and the questionnaire link was sent to mothers in six Arabic countries.

Data collection and instruments

This study was conducted between January 2024 and July 2024. The questionnaire was developed by the authors based on a literature review and related articles and consisted of two main parts: socio-demographic characteristics of mothers includes: (age, level of education of women, occupation of woman, nationality), the second one consists of Questions to understanding the avoidance of Middle East women to use family planning methods is consist of (51) items which are divided in to three main domains first one is (effective domain) consist of (12) items, the second one is (behavioral domain) consist of (17) items, and the last one is (cognitive domain) consist of (22) items.²⁸^,²⁹ The questionnaire was sent to a panel of experts to assess its content validity. To assess its reliability, a validated questionnaire was distributed to 20 mothers. Cronbach’s alpha was 0.768, indicating the questionnaire’s consistent reliability.

Data analysis

For the purpose of scoring the scale, three Likert scale was used and scored as follows: (1) never, (2), sometimes, and (3) always. The significant of each barrier in the scale was determined by calculating the range score for mean and determining the maximum and minimum score and rated into three levels: low= 1 – 1.66, moderate= 1.67 – 2.33, and high= 2.34 – 3.

For the purpose of analyzing data, the Statistical Package for Social Science (SPSS- version 24.0)³⁰ was used through application of descriptive statistics which includes: frequencies, percentages, and mean scores which were used to describe the socio-demographic characteristics and also describe the severity of barrier’s significant.

Ethical considerations

The study protocol was approved by the Scientific Research Ethical Committee in the College of Nursing at the University of Baghdad Ref. No. 8: January 16, 2024. In addition, permission was obtained from the Iraqi Ministry of Health/Training and Developmental Department to collect data from primary healthcare centers in six Arabic countries. Ethical considerations, including the nature and aims of the study, voluntary participation, right to withdraw from participation, protection of confidentiality, privacy of the informants, use and publication of the study results, storage of data, and benefits of the study, were explained to the participants by the researcher. This information was conveyed in the human ethics form and verbally reinforced before data collection. The researcher informed the women about their rights of voluntarily participation, withdraw at any time, confidentiality, and privacy. Women who agreed to participate were asked to sign the consent form. Study ethical considerations including the nature and aims of the study, voluntary participation, the right to withdraw from participation, the protection of confidentiality and privacy of the informants, the use and publication of the study results, the storage of data, and benefits of the study were explained in writing to candidates. This information was conveyed in the human ethics application form. It was also verbally reinforced before the conduction of the interview.

Results

The analysis of this Table 1 shows that women are with average age of 32.23 ± 7.9 years in which the highest percentage is seen with age group of 30-39 years (40.4%). Regarding level of education, the highest percentage is seen with 22.7% of those who graduated from institute or college. The nationality of women distributed equally from various countries; Iraq (16.7%), Lebanon (16.7%), Jordan (16.7%), Yemen (16.7%), Egypt (16.7%), and Saudi Arabia (16.7%).

Table 1. Socio-demographic Demographic Characteristics of Women.

Characteristics		No	%
Age (years) M±SD= 32.23±7.9	Less than 20	6	3
	20 – 29	74	37.4
	30 – 39	80	40.4
	40 ≤	38	19.2
	Total	198	100
Wife’s level of education	Doesn't read & write	9	4.6
	Read and write	28	14.2
	Primary	35	17.7
	Intermediate	31	15.6
	Secondary	41	20.7
	Institute/College	45	22.7
	Postgraduate	8	4.1
	Total	198	100
Wife’s Occupation	Housewife	100	50.5
	Governmental employee	94	47.5
	Free works	4	2
	Total	198	100
Nationality	Iraq	33	16.7
	Lebanon	33	16.7
	Jordan	33	16.7
	Yemen	33	16.7
	Egypt	33	16.7
	Saudi Arabia	33	16.7
	Total	198	100

Table 2 indicates that women have high affective barrier to avoid uses family planning methods (total grand mean = 2.60); the mean scores indicate high among most of affective barrier except (Contraceptives can actually make intercourse seem more pleasurable) and (Contraceptives are not really necessary unless a couple has engaged in intercourse more than once) that show moderate.

Table 2. Evaluation of Affective barrier to avoid use of family planning methods among Women (N=198).

List	Causes	Mean	Evaluation
1	Feel that family planning methods protect me from pregnancy and make me not feel anxious during sexual intercourse.	2.81	High
2	Feel more relaxed during intercourse if a contraceptive method is used.	2.69	High
3	Feel contraceptives make pregnancy seem too planned.	2.80	High
4	Feel contraceptives make intercourse seem too planned.	2.51	High
5	Contraceptives can actually make intercourse seem more pleasurable.	2.24	Moderate
6	Contraceptives are worth using, even if the monetary cost is high.	2.70	High
7	Would feel embarrassed discussing contraception with my friends.	2.56	High
8	Sex is not fun if a contraceptive is used.	2.36	High
9	Contraceptives are not really necessary unless a couple has engaged in intercourse more than once.	2.25	Moderate
10	Feel that females who use contraceptives methods kill their children.	2.83	High
11	I feel that contraception is solely my husband's responsibility.	2.86	High
12	I feel the limitations when using contraceptive methods.	2.66	High
	*Total Grand mean*	*2.60*	High

Table 3 reveals that women have high behavioral barriers to avoid uses family planning methods (total grand mean = 2.56); the mean scores indicate high among most of behavioral barriers except (After a sudden intercourse, I use an emergency contraceptive method to prevent pregnancy), (I would practice contraception even if my partner did not want me to) and (I prefer that my husband be receptive to the responsibility of using contraceptive methods) that show moderate.

Table 3. Evaluation of Behavioral barrier to avoid use of family planning methods among Women (N = 198).

List	Causes	Mean	Evaluation
1	To get the number of children I want, using contraception methods.	2.86	High
2	For the sake of my family and children, I use contraception methods.	2.88	High
3	I won't have enough time to take care of myself and my other children if I don't use contraception methods.	2.76	High
4	After a sudden intercourse, I use an emergency contraceptive method to prevent pregnancy.	2.19	Moderate
5	I would practice contraception even if my partner did not want me to.	1.98	Moderate
6	If I experienced negative side effects from a contraceptive method, I would use a different method.	2.74	High
7	I would not have intercourse if no contraceptive method was available.	2.27	High
8	Couples should talk about contraception before having intercourse.	2.89	High
9	If I don't use family planning methods, I will get an unwanted child or at an inappropriate time.	2.67	High
10	Using contraceptives makes a relationship seem too permanent.	2.53	High
11	In the future, I plan to use contraceptives any time I have intercourse.	2.59	High
12	I prefer that my husband be receptive to the responsibility of using contraceptive methods.	2.07	Moderate
13	I prefer to use contraceptives during intercourse.	2.92	High
14	I do not talk about contraception with my friends.	2.63	High
15	I don't know how to use contraception methods so I don't use them and avoid them.	2.65	High
16	Because of the side effects, I don't use contraception methods.	2.40	High
17	The use of contraceptive methods is not acceptable to my husband.	2.58	High
	*Total Grand mean*	*2.56*	High

Table 4 depicts that women have high cognitive barriers to avoid uses family planning methods (total grand mean = 2.56); the mean scores indicate high among most of cognitive barrier except (I think that the natural method is effective in family planning), (I think implantation is good for family planning) and (I think it is better to have a tubal ligation to prevent childbearing) that show moderate.

Table 4. Evaluation of Cognitive barrier to avoid use of Family Planning Methods among Women (N=198).

List	Causes	Mean	Evaluation
1	I think that a woman who uses contraceptive methods has enough time to take care of herself and her husband instead of wasting time on a large number of children.	2.90	High
2	I encourage my friends to use contraceptives.	2.62	High
3	It is no trouble to use contraceptives.	2.95	High
4	Using contraceptives is much more desirable than having an abortion.	2.95	High
5	I think that contraceptive methods make my life more stable.	2.75	High
6	I think that if I do not use family planning methods I will have a large number of children and will not get their right to breastfeed and care.	2.73	High
7	I think my overall health would decline as a result of the variety and proximity of births if I do not use contraception methods.	2.67	High
8	I think that the natural method (method of calculation) is effective in family planning.	2.24	Moderate
9	I think pills are effective at family planning.	2.66	High
10	I think contraceptive injection is effective at family planning.	2.24	Moderate
11	I think using an IUD is an effective method of family planning.	2.45	High
12	I think implantation is good for family planning.	2.11	Moderate
13	I think that it is possible to rely on the husband for use of contraceptive.	2.49	High
14	I think it is better to have a tubal ligation to prevent childbearing.	1.92	Moderate
15	I think that contraceptive methods maintain my reproductive health.	2.49	High
16	I think it is wrong to use contraceptive methods because they place restrictions on couples.	2.64	High
17	I think there are no integrated contraceptive methods that provide 100% pregnancy protection.	2.38	High
18	I think that contraceptive methods are against the teachings of Islam.	2.54	High
19	I think contraceptives are difficult to obtain.	2.69	High
20	I think contraceptives reduce the sex drive.	2.47	High
21	I think that contraceptive methods are costly.	2.68	High
22	I think Contraceptives weaken the marital relation.	2.69	High
	*Total Grand mean*	*2.56*	*High*

Discussion

Total grand mean = 2.60 indicates that women have a high affective barrier to using family planning methods; mean scores are high for most affective barriers, with the exception of (Contraceptives can actually make intercourse seem more pleasurable) and (Contraceptives are not really necessary unless a couple has engaged in intercourse more than once) that show moderate.

Approximately 17% of married women worldwide, or over 100 million women in less developed countries, would prefer not to get pregnant but are not utilizing family planning. Unwanted or pregnancies might result from unmet contraceptive needs. Which puts women, their families, and society at risks. Approximately 25% of pregnancies in less developed countries are unplanned.³¹challenges pertaining to reproduction can occasionally exist, such as (lack of sexual activity or prolonged intervals between sexual activity, fear of contraceptive side effects including bleeding, spotting, amenorrhea, or incidence of breast tumors or any other gynecological oncology). Furthermore, some women choose not to use contraceptives because they believe that they are not truly necessary until a couple has had multiple sexual encounters. This is especially true for women whose husbands work outside the home for a several days. The involvement of the husband frequently has a detrimental impact on women’s decisions to use or not use family planning methods. Instead, it pushes women to have a large number of children, particularly in rural countries where a large family is seen as a source of strength and pride for the father. In many cases the role of husband is negatively affected women’s decisions about use or abstain family planning methods. Rather the forces the women to have a lot of children, especially in rural societies that believe that the large number of children is a source of proud and strength for the father.

The population of Iraq has grown at an average yearly growth rate of 3% over the past three decades.³² Which, together with Yemen and Palestine, is regarded as one of the highest in the Region.³³At the moment, 70% of people reside in cities.³⁴ Women in their twenties of the overall population, 20% are between the ages of 15 and 49.³⁵ With 22% of the population living below the federal poverty line and a comparatively high maternal mortality rate (50 deaths per 100,000 live births), poverty and unemployment are still high. There are disparities as well: the poverty rate doubles in rural areas, 22% of women are illiterate, and only 10% of the workforce is made up of women.³⁶

Women have high behavioral barriers to abstention of family planning methods (total grand mean= 2.56); the mean scores indicate high among most of behavioral barriers except (After a sudden intercourse, I use an emergency contraceptive method to prevent pregnancy), (I would practice contraception even if my partner did not want me to) and (I prefer that my husband be receptive to the responsibility of using contraceptive methods) that show moderate.

Family planning service utilization decisions are influenced by a variety of service-related and demographic constraints. By comprehending and utilizing data on unmet need, policymakers and program managers can enhance family planning initiatives. Taking into account the traits of women and couples with unfulfilled needs and trying to remove barriers that keep them from selecting and utilizing family planning techniques.³⁷ Sometimes the desire for the most effective methods creates barriers that prevent women from using family planning methods successfully, these barriers include the method’s induction of serious side effects, such as severe headaches, severe depression, severe bleeding, and extreme pain in the chest or abdomen. Some women also prefer natural methods because they think they are safe and effective, and some women avoid family planning methods because they are religiously prohibited from doing so or because they cannot access them cost free, and many of them are low-income. Together, these barriers force women to have unintended pregnancies, large families with lots of children, and sick mothers who are forced to care for their large families.

Concerning barriers related to cognitive the study shows that women have high cognitive barriers to avoid uses family planning methods (total grand mean = 2.56); the mean scores indicate high among most of cognitive barrier except (I think that the natural method is effective in family planning), (I think implantation is good for family planning) and (I think it is better to have a tubal ligation to prevent childbearing) that show moderate.

In order to stabilize the global population, it is necessary to remove barriers that prevent all women from accessing high-quality contraceptive and family planning services. Prior studies on the obstacles to using FP services have emphasized the significance of focusing on factors other than physical access when analyzing obstacles resulting from administrative, cognitive, emotional, and cultural elements in addition to physical obstacles and method-specific obstacles.³⁸

There are various types of reported barriers for both the discontinued group and the non-users. Cognitive, cultural and demographic barriers were the main barriers that lead to not using/discontinuation of family planning methods followed by barriers related to the method itself and reproductive barriers. The administrative and physical barriers were the least reported ones.³⁹^–⁴¹

In addition to social, cultural, and economic restrictions, Middle Eastern women continue to confront other obstacles in their quest for family planning services. This piece emphasizes the urgent necessity to remove these obstacles by disseminating promotional messaging. Providing counseling to women, particularly during postpartum visits, in order to dispel myths and assist them in making an informed decision. Providers in these fields should keep a variety of contraceptives on hand as well as offer counseling to help women and couples meet their contraceptive needs. This will allow women to select the methods that best suits their needs. Postpartum, breastfeeding, and menopausal women should receive counseling regarding their risk of getting pregnant, how to satisfy their family planning needs, and how to raise money to cover gaps in government programs. Governments can improve individual rights, growth population, and accomplish development goals particularly MDG 5, which calls for improved maternal health by reducing the unmet demand for family planning.⁶^,⁴²^,⁴³

Conclusions

The study concluded that there are many potential barriers which can negatively impact the Middle East women’s decision about their reproductive life includes affective, behavioral and cognitive barriers, depending on how they influence the decision-making process. The majority of barriers were impacted by understanding family planning, getting assistance from others (husbands, society, friends, etc.), adhering to social norms and culture, and giving family planning priority. Despite the fact that family planning faces several challenges in the Middle East, numerous governments and civil society organizations are working to find solutions to improve access to family planning services, promote education, hold candid conversations about reproductive health with local communities. Empowering the role of nurse in family planning to educate the couples about contraceptive methods and how to help them to choice the appropriate method.

Ethics and consent

The ethical approval was obtained from the Institutional Review Board (IRB) in College of Nursing at University of Baghdad with a reference number 8 in 16 January, 2024.

All participants provided informed written consent to participate in the study. The researcher informed the women about their rights of voluntarily participation, withdraw at any time, confidentiality, and privacy. Women who agreed to participate were asked to sign the consent form. Study ethical considerations including the nature and aims of the study, voluntary participation, the right to withdraw from participation, the protection of confidentiality and privacy of the informants, the use and publication of the study results, the storage of data, and benefits of the study were explained in writing to candidates. This information was conveyed in the human ethics application form. It was also verbally reinforced before the conduction of the interview.

CRediT authorship contribution statement

Hawraa Hussein Ghafel: Writing – original draft, Supervision, Resources, Project administration, Investigation, Funding acquisition, Data curation, Conceptualization.

Data availability

Underlying data

Figshare: Understanding of Middle East Women’s Decisions and barriers to use Family Planning Methods, https://doi.org/10.6084/m9.figshare.26355775 ²⁹

This project contains the following extended data:

• Data Data.xlsx

Extended data

Figshare: Questionnaires, https://doi.org/10.6084/m9.figshare.26355694 ²⁸

This project contains the following extended data:

• Questionnaire in the English language

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Acknowledgments

The author appreciate the efforts and dedication of a Professor Dr. Sadeq Abdul Hussein Hassan, a professor Dr. Qahtan Qassem Mohammed (faculty members at College of Nursing, University of Baghdad) for their help. Without the women’s cooperation and assistance, the data could not have been gathered. The author greatly value their participation and cooperation.

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22. Sammouri J, Khachfe HH, Fares MY, et al.: Deliveries in Lebanon, the Country with the Highest Refugee Density in the World: A Descriptive Review. Matern. Child Health J. 2024 Apr; 28(4): 601–608. Epub 2023 Nov 18. PubMed Abstract | Publisher Full Text
23. Fischbach MR: Spotlight: Lebanon. Popul Today. 1998 Jul-Aug; 26(7-8): 7. PubMed Abstract Reference Source
24. Darroch JE, Sedgh G, Ball H: Contraceptive Technologies: Responding to Women’s Needs. New York: Guttmacher Institute; 2011.
25. Roudi-Fahimi F, Monem AA: Unintended Pregnancies in the Middle East and North Africa. Washington, DC: PRB; 2010.
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30. Statistical Package for Social Science (SPSS- version 24.0). http
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Comments on this article Comments (1)

Version 2

VERSION 2 PUBLISHED 16 Jul 2025

Revised

Comment

Version 1

VERSION 1 PUBLISHED 06 Aug 2024

Discussion is closed on this version, please comment on the latest version above.

Reader Comment 23 Aug 2024

Resti Tito Villarino, Local Research Ethics Committee, Cebu Technological University, Cebu City, Philippines

23 Aug 2024

Reader Comment
1. Title and Abstract:
The title adequately reflects the study's content. However, it could be more specific by mentioning the countries involved and the types of barriers examined.

... Continue reading
1. Title and Abstract:
The title adequately reflects the study's content. However, it could be more specific by mentioning the countries involved and the types of barriers examined.

The abstract provides a concise overview of the study but could be improved by:

Specifying the six Arabic countries in the methodology section

Including more quantitative results (e.g., percentages for each type of barrier)

Elaborating on the implications of the findings

2. Introduction:
Areas for improvement:

The literature review lacks depth and critical analysis of existing research.

Many references are outdated (pre-2020).

The research gap and rationale for this specific study are not clearly articulated.

There is no clear theoretical framework presented.

3. Methods:
Areas for improvement:

More details are needed on the development and validation of the questionnaire.

There is a lack of information on how the questionnaire was translated (if applicable) and culturally adapted for different countries.

There is no mention of potential confounding variables or how they were controlled for

Limited information on data analysis techniques beyond descriptive statistics

4. Results:
Areas for improvement:

Lack of inferential statistics to explore relationships between variables.

There is no comparison of results between the six countries studied.

Limited analysis of how demographic factors relate to the barriers identified.

Some tables could be simplified or combined for better readability.

5. Discussion:
Areas for improvement:

Limited critical analysis of the study's findings.

Insufficient comparison with previous research findings.

There is a lack of discussion on how the identified barriers might be addressed.

No clear discussion of the study's limitations.

Implications for policy and practice are not thoroughly explored.

6. Conclusion:
The conclusion summarizes the main findings but is relatively brief and general. It could be improved by:

Providing more specific conclusions related to each type of barrier.

Offering concrete recommendations based on the findings.

Suggesting directions for future research.

Overall comments: This study addresses an important topic in reproductive health in the Middle East. However, there are several areas where the manuscript could be substantially improved:

The introduction needs a more comprehensive and up-to-date literature review, a clearer articulation of the research gap, and a theoretical framework.

The methods section should detail questionnaire development, validation, and cultural adaptation.

The results section would benefit from more advanced statistical analyses, including comparisons between countries and exploring relationships between variables.

The discussion needs more critical analysis, thorough comparison with existing literature, and exploration of implications.

The conclusion should offer more specific insights and recommendations based on the findings.

Throughout the paper, some grammatical and structural issues should be addressed to improve clarity and readability.
1. Title and Abstract:
The title adequately reflects the study's content. However, it could be more specific by mentioning the countries involved and the types of barriers examined.

The abstract provides a concise overview of the study but could be improved by:

Specifying the six Arabic countries in the methodology section

Including more quantitative results (e.g., percentages for each type of barrier)

Elaborating on the implications of the findings

2. Introduction:
Areas for improvement:

The literature review lacks depth and critical analysis of existing research.

Many references are outdated (pre-2020).

The research gap and rationale for this specific study are not clearly articulated.

There is no clear theoretical framework presented.

3. Methods:
Areas for improvement:

More details are needed on the development and validation of the questionnaire.

There is a lack of information on how the questionnaire was translated (if applicable) and culturally adapted for different countries.

There is no mention of potential confounding variables or how they were controlled for

Limited information on data analysis techniques beyond descriptive statistics

4. Results:
Areas for improvement:

Lack of inferential statistics to explore relationships between variables.

There is no comparison of results between the six countries studied.

Limited analysis of how demographic factors relate to the barriers identified.

Some tables could be simplified or combined for better readability.

5. Discussion:
Areas for improvement:

Limited critical analysis of the study's findings.

Insufficient comparison with previous research findings.

There is a lack of discussion on how the identified barriers might be addressed.

No clear discussion of the study's limitations.

Implications for policy and practice are not thoroughly explored.

6. Conclusion:
The conclusion summarizes the main findings but is relatively brief and general. It could be improved by:

Providing more specific conclusions related to each type of barrier.

Offering concrete recommendations based on the findings.

Suggesting directions for future research.

Overall comments: This study addresses an important topic in reproductive health in the Middle East. However, there are several areas where the manuscript could be substantially improved:

The introduction needs a more comprehensive and up-to-date literature review, a clearer articulation of the research gap, and a theoretical framework.

The methods section should detail questionnaire development, validation, and cultural adaptation.

The results section would benefit from more advanced statistical analyses, including comparisons between countries and exploring relationships between variables.

The discussion needs more critical analysis, thorough comparison with existing literature, and exploration of implications.

The conclusion should offer more specific insights and recommendations based on the findings.

Throughout the paper, some grammatical and structural issues should be addressed to improve clarity and readability.
Competing Interests: None declared. Close
Report a concern
Discussion is closed on this version, please comment on the latest version above.

Author details Author details

Doctor in Maternal and Neonate Nursing Department, College of Nursing, University of Baghdad, Bab Al-Mua’adham, Baghdad City, 10011, Iraq

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (2)

version 2

Revised

Published: 16 Jul 2025, 13:898

https://doi.org/10.12688/f1000research.154232.2

version 1

Published: 06 Aug 2024, 13:898

https://doi.org/10.12688/f1000research.154232.1

© 2024 Ghafel HH. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Ghafel HH. Understanding of middle east women’s decisions and barriers to use family planning methods [version 1; peer review: 3 not approved]. F1000Research 2024, 13:898 (https://doi.org/10.12688/f1000research.154232.1)

NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.

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Open Peer Review

Current Reviewer Status: ?

Key to Reviewer Statuses VIEW HIDE

ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions

Version 1

VERSION 1

PUBLISHED 06 Aug 2024

Views

Reviewer Report 02 Apr 2025

Barbara Friedland, Center for Biomedical Research, Population Council, New York, New York, USA

Not Approved

https://doi.org/10.5256/f1000research.169229.r367544

The article is about barriers to contraception based on a cross-sectional survey implemented in 6 countries. Women responded to a survey with a 3-point Likert scale measuring attitudes and behaviors related to contraception. However, the survey instrument is problematic as presented:

- if the survey is meant to be a scale, it is unclear how the items were developed, tested, validated, etc.
- there are multiple overlapping items between the 3 domains in the survey/scale
- items are not all framed in the same direction; for some items, a 3 -- "always" -- would be a positive response whereas for other items a 1 or "never" would be a positive response. Because of this, it is not possible to arrive at mean scores that represent an overall positive or negative attitude or experience related to contraception.

Therefore, the article does not make a compelling case that there are barriers to contraceptive use.

Other concerns that are less critical are:

It is unclear why the 6 countries were chosen -- what do they have in common? What is different among them? It would be helpful to understand why this specific set of 6 countries was included.

The title indicated that the study was focused on barriers to contraceptive use, but "unmet need" is only applicable to people who do not want to become pregnant yet are not doing anything to prevent pregnancy. It is unclear if all women in the study did not want to get pregnant.

The sample size is not adequately explained -- what is the outcome that the sample size was based upon? Regardless of outcomes, 198 women across 6 countries is a very small sample upon which to base any conclusions.

Is the work clearly and accurately presented and does it cite the current literature?

No
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

No
Are all the source data underlying the results available to ensure full reproducibility?

No source data required
Are the conclusions drawn adequately supported by the results?

No

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: I am researcher based at an international non-profit institution with a masters in public health conducting clinical and behavioral research. I have expertise in developing and implementing surveys, including scales for measuring latent constructs.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

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Report a concern

Author Response 23 Aug 2025

Hawraa Ghafel , Doctor in Maternal and Neonate Nursing Department, College of Nursing, University of Baghdad, Bab Al-Mua’adham, 10011, Iraq

23 Aug 2025

Author Response

Dear Reviewer,
Thank you very much for your thoughtful and valuable feedback on my manuscript. I sincerely appreciate your careful review and constructive suggestions, which have significantly contributed to enhancing ... Continue reading Dear Reviewer,
Thank you very much for your thoughtful and valuable feedback on my manuscript. I sincerely appreciate your careful review and constructive suggestions, which have significantly contributed to enhancing the clarity and rigor of the revised version. Please find below my responses to the issues you raised:
1. Survey instrument development and validation
I fully acknowledge the concerns regarding the survey tool. In the revised manuscript, I have included a detailed explanation of the item development process, which was informed by a review of relevant literature and pre-tested in two countries to ensure clarity and cultural appropriateness.
I have also clarified the steps taken to ensure content validity, and while full psychometric validation was not feasible due to sample size limitations, I have transparently acknowledged this limitation and its implications for interpretation.
2. Overlapping and inconsistent item framing
Thank you for pointing out the issue of overlapping items and inconsistent directionality. I have carefully reviewed the entire set of items across the three domains and made revisions to remove redundancy and ensure greater consistency in how the items are framed.
Furthermore, I clarified in the methods section that items with reversed scoring were re-coded appropriately during the analysis phase. I also addressed the limitations of relying on mean scores in the discussion, and emphasized that the results should be interpreted as indicative of patterns rather than definitive measures of attitude strength.
3. Justification for country selection
In selecting the countries included in this study, a purposive sampling strategy was employed to ensure a diverse yet representative understanding of attitudes and practices toward family planning among Middle Eastern women. Six Arab countries were chosen: Iraq, Egypt, Saudi Arabia, Jordan, Lebanon, and Yemen.
The selection was primarily based on fertility rate indicators, as reported by recent demographic and health data. Countries with high fertility rates, such as Iraq, Egypt, Saudi Arabia, and Yemen, were prioritized to explore potential gaps in family planning awareness and utilization. Jordan and Lebanon were included to provide comparative insights from countries with relatively lower fertility rates but similar cultural and regional contexts.
This combination allows the study to capture a broader spectrum of experiences and challenges, offering a more nuanced understanding of family planning behaviors across varying socio-economic and demographic profiles within the Arab world.
4. Clarity on "unmet need"
Thank you for raising this important distinction. I have clarified in the revised text that while the study explores the attitudes and practice, it does not exclusively focus on women with an "unmet need" as defined by demographic health surveys. This distinction has now been made explicit, and references to "unmet need" have been revised or removed to avoid confusion.
5. Sample size explanation
I have expanded the description of the sample size estimation, specifying the assumptions used (including estimated proportion and confidence level), and acknowledged the limitations of the small, purposive sample. As noted, while the total number of 198 women across six countries limits the generalizability of the findings, the study is intended as an exploratory effort to identify patterns and guide future, larger-scale research.
Once again, I truly appreciate your careful critique. Your comments were extremely helpful in refining the methodology and strengthening the manuscript overall. I hope the revisions adequately address your concerns.
Kind regards,
Dear Reviewer,
Thank you very much for your thoughtful and valuable feedback on my manuscript. I sincerely appreciate your careful review and constructive suggestions, which have significantly contributed to enhancing the clarity and rigor of the revised version. Please find below my responses to the issues you raised:
1. Survey instrument development and validation
I fully acknowledge the concerns regarding the survey tool. In the revised manuscript, I have included a detailed explanation of the item development process, which was informed by a review of relevant literature and pre-tested in two countries to ensure clarity and cultural appropriateness.
I have also clarified the steps taken to ensure content validity, and while full psychometric validation was not feasible due to sample size limitations, I have transparently acknowledged this limitation and its implications for interpretation.
2. Overlapping and inconsistent item framing
Thank you for pointing out the issue of overlapping items and inconsistent directionality. I have carefully reviewed the entire set of items across the three domains and made revisions to remove redundancy and ensure greater consistency in how the items are framed.
Furthermore, I clarified in the methods section that items with reversed scoring were re-coded appropriately during the analysis phase. I also addressed the limitations of relying on mean scores in the discussion, and emphasized that the results should be interpreted as indicative of patterns rather than definitive measures of attitude strength.
3. Justification for country selection
In selecting the countries included in this study, a purposive sampling strategy was employed to ensure a diverse yet representative understanding of attitudes and practices toward family planning among Middle Eastern women. Six Arab countries were chosen: Iraq, Egypt, Saudi Arabia, Jordan, Lebanon, and Yemen.
The selection was primarily based on fertility rate indicators, as reported by recent demographic and health data. Countries with high fertility rates, such as Iraq, Egypt, Saudi Arabia, and Yemen, were prioritized to explore potential gaps in family planning awareness and utilization. Jordan and Lebanon were included to provide comparative insights from countries with relatively lower fertility rates but similar cultural and regional contexts.
This combination allows the study to capture a broader spectrum of experiences and challenges, offering a more nuanced understanding of family planning behaviors across varying socio-economic and demographic profiles within the Arab world.
4. Clarity on "unmet need"
Thank you for raising this important distinction. I have clarified in the revised text that while the study explores the attitudes and practice, it does not exclusively focus on women with an "unmet need" as defined by demographic health surveys. This distinction has now been made explicit, and references to "unmet need" have been revised or removed to avoid confusion.
5. Sample size explanation
I have expanded the description of the sample size estimation, specifying the assumptions used (including estimated proportion and confidence level), and acknowledged the limitations of the small, purposive sample. As noted, while the total number of 198 women across six countries limits the generalizability of the findings, the study is intended as an exploratory effort to identify patterns and guide future, larger-scale research.
Once again, I truly appreciate your careful critique. Your comments were extremely helpful in refining the methodology and strengthening the manuscript overall. I hope the revisions adequately address your concerns.
Kind regards,
Competing Interests: i have no any competing interest Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 23 Aug 2025

Hawraa Ghafel , Doctor in Maternal and Neonate Nursing Department, College of Nursing, University of Baghdad, Bab Al-Mua’adham, 10011, Iraq

23 Aug 2025

Author Response

Dear Reviewer,
Thank you very much for your thoughtful and valuable feedback on my manuscript. I sincerely appreciate your careful review and constructive suggestions, which have significantly contributed to enhancing ... Continue reading Dear Reviewer,
Thank you very much for your thoughtful and valuable feedback on my manuscript. I sincerely appreciate your careful review and constructive suggestions, which have significantly contributed to enhancing the clarity and rigor of the revised version. Please find below my responses to the issues you raised:
1. Survey instrument development and validation
I fully acknowledge the concerns regarding the survey tool. In the revised manuscript, I have included a detailed explanation of the item development process, which was informed by a review of relevant literature and pre-tested in two countries to ensure clarity and cultural appropriateness.
I have also clarified the steps taken to ensure content validity, and while full psychometric validation was not feasible due to sample size limitations, I have transparently acknowledged this limitation and its implications for interpretation.
2. Overlapping and inconsistent item framing
Thank you for pointing out the issue of overlapping items and inconsistent directionality. I have carefully reviewed the entire set of items across the three domains and made revisions to remove redundancy and ensure greater consistency in how the items are framed.
Furthermore, I clarified in the methods section that items with reversed scoring were re-coded appropriately during the analysis phase. I also addressed the limitations of relying on mean scores in the discussion, and emphasized that the results should be interpreted as indicative of patterns rather than definitive measures of attitude strength.
3. Justification for country selection
In selecting the countries included in this study, a purposive sampling strategy was employed to ensure a diverse yet representative understanding of attitudes and practices toward family planning among Middle Eastern women. Six Arab countries were chosen: Iraq, Egypt, Saudi Arabia, Jordan, Lebanon, and Yemen.
The selection was primarily based on fertility rate indicators, as reported by recent demographic and health data. Countries with high fertility rates, such as Iraq, Egypt, Saudi Arabia, and Yemen, were prioritized to explore potential gaps in family planning awareness and utilization. Jordan and Lebanon were included to provide comparative insights from countries with relatively lower fertility rates but similar cultural and regional contexts.
This combination allows the study to capture a broader spectrum of experiences and challenges, offering a more nuanced understanding of family planning behaviors across varying socio-economic and demographic profiles within the Arab world.
4. Clarity on "unmet need"
Thank you for raising this important distinction. I have clarified in the revised text that while the study explores the attitudes and practice, it does not exclusively focus on women with an "unmet need" as defined by demographic health surveys. This distinction has now been made explicit, and references to "unmet need" have been revised or removed to avoid confusion.
5. Sample size explanation
I have expanded the description of the sample size estimation, specifying the assumptions used (including estimated proportion and confidence level), and acknowledged the limitations of the small, purposive sample. As noted, while the total number of 198 women across six countries limits the generalizability of the findings, the study is intended as an exploratory effort to identify patterns and guide future, larger-scale research.
Once again, I truly appreciate your careful critique. Your comments were extremely helpful in refining the methodology and strengthening the manuscript overall. I hope the revisions adequately address your concerns.
Kind regards,
Dear Reviewer,
Thank you very much for your thoughtful and valuable feedback on my manuscript. I sincerely appreciate your careful review and constructive suggestions, which have significantly contributed to enhancing the clarity and rigor of the revised version. Please find below my responses to the issues you raised:
1. Survey instrument development and validation
I fully acknowledge the concerns regarding the survey tool. In the revised manuscript, I have included a detailed explanation of the item development process, which was informed by a review of relevant literature and pre-tested in two countries to ensure clarity and cultural appropriateness.
I have also clarified the steps taken to ensure content validity, and while full psychometric validation was not feasible due to sample size limitations, I have transparently acknowledged this limitation and its implications for interpretation.
2. Overlapping and inconsistent item framing
Thank you for pointing out the issue of overlapping items and inconsistent directionality. I have carefully reviewed the entire set of items across the three domains and made revisions to remove redundancy and ensure greater consistency in how the items are framed.
Furthermore, I clarified in the methods section that items with reversed scoring were re-coded appropriately during the analysis phase. I also addressed the limitations of relying on mean scores in the discussion, and emphasized that the results should be interpreted as indicative of patterns rather than definitive measures of attitude strength.
3. Justification for country selection
In selecting the countries included in this study, a purposive sampling strategy was employed to ensure a diverse yet representative understanding of attitudes and practices toward family planning among Middle Eastern women. Six Arab countries were chosen: Iraq, Egypt, Saudi Arabia, Jordan, Lebanon, and Yemen.
The selection was primarily based on fertility rate indicators, as reported by recent demographic and health data. Countries with high fertility rates, such as Iraq, Egypt, Saudi Arabia, and Yemen, were prioritized to explore potential gaps in family planning awareness and utilization. Jordan and Lebanon were included to provide comparative insights from countries with relatively lower fertility rates but similar cultural and regional contexts.
This combination allows the study to capture a broader spectrum of experiences and challenges, offering a more nuanced understanding of family planning behaviors across varying socio-economic and demographic profiles within the Arab world.
4. Clarity on "unmet need"
Thank you for raising this important distinction. I have clarified in the revised text that while the study explores the attitudes and practice, it does not exclusively focus on women with an "unmet need" as defined by demographic health surveys. This distinction has now been made explicit, and references to "unmet need" have been revised or removed to avoid confusion.
5. Sample size explanation
I have expanded the description of the sample size estimation, specifying the assumptions used (including estimated proportion and confidence level), and acknowledged the limitations of the small, purposive sample. As noted, while the total number of 198 women across six countries limits the generalizability of the findings, the study is intended as an exploratory effort to identify patterns and guide future, larger-scale research.
Once again, I truly appreciate your careful critique. Your comments were extremely helpful in refining the methodology and strengthening the manuscript overall. I hope the revisions adequately address your concerns.
Kind regards,
Competing Interests: i have no any competing interest Close
Report a concern

Views

Reviewer Report 20 Feb 2025

Augustus Osborne, Njala University, Freetown, Sierra Leone

Not Approved

https://doi.org/10.5256/f1000research.169229.r367545

Peer Review Report
Manuscript Title: Understanding of Middle East Women’s Decisions and Barriers to Use Family Planning Methods
This manuscript addresses a critical and timely issue in reproductive health, focusing on the cognitive, affective, and behavioral barriers faced by women in six Middle Eastern countries when making decisions about family planning. While the study has the potential to contribute to the understanding of family planning challenges in the region, there are significant gaps in the methodology, analysis, and presentation of findings that need to be addressed to improve its scientific rigor and clarity.
1. Abstract
- Specify the six countries included in the study in the methodology section of the abstract.
- Include key quantitative results (e.g., percentages of women experiencing each type of barrier).
- Elaborate on the implications of the findings, particularly for policy and practice.
2. Introduction
- The literature review lacks depth and critical engagement with recent studies, with many references predating 2020.
- The rationale for selecting the six countries (Iraq, Lebanon, Jordan, Yemen, Egypt, and Saudi Arabia) is not explained.
- There is no clear theoretical framework to support the categorization of barriers into cognitive, affective, and behavioral domains. Introduce a theoretical framework to define and support the categorization of barriers into cognitive, affective, and behavioral domains.
3. Methodology
- The sample size (198 women) is small and not representative of the diverse populations in the six countries.
- The use of a non-probability purposive sampling method limits the generalizability of the findings.
- The questionnaire's development, validation, and cultural adaptation are not adequately detailed.
- The use of a 3-point Likert scale is insufficient to capture nuanced responses and limits the depth of analysis.
- Confounding variables (e.g., socioeconomic status, urban/rural residence) are not addressed.
4. Results
- The analysis is limited to descriptive statistics, with no inferential statistics to explore relationships between variables or compare results across countries.
- The presentation of results is repetitive, with little synthesis or interpretation.
- There is no analysis of how demographic factors (e.g., age, education, nationality) relate to the identified barriers.
- Include inferential statistics (e.g., chi-square tests, regression analysis) to explore relationships between variables and compare results across countries.
- Synthesize the findings to provide a clearer narrative rather than listing results without interpretation.
- Analyze how demographic factors (e.g., age, education, nationality) influence the barriers identified.
5. Discussion
- The discussion lacks critical analysis and comparison with existing literature.
- It generalizes beyond the findings, making unsupported claims about family planning in the Middle East.
- The study's limitations are not adequately addressed.
- There is insufficient discussion of practical implications and recommendations for addressing the barriers identified.
6. Conclusion
- Provide specific conclusions related to each type of barrier (affective, behavioral, cognitive).
- Offer concrete recommendations for addressing the barriers identified, including policy changes, educational interventions, and community engagement.
- Suggest directions for future research, such as exploring barriers in other Middle Eastern countries or using larger, more representative samples.
7. References
- Many references are outdated (pre-2020).
- Some references are not directly relevant to the study's focus.
8. Language and Formatting
- There are grammatical errors and awkward phrasing throughout the manuscript.
- Some sections are repetitive and could be streamlined.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

No

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Public Health

CITE

Report a concern

Author Response 23 Aug 2025

Hawraa Ghafel , Doctor in Maternal and Neonate Nursing Department, College of Nursing, University of Baghdad, Bab Al-Mua’adham, 10011, Iraq

23 Aug 2025

Author Response
Dear Reviewer,
Thank you very much for your thoughtful and comprehensive review of my manuscript. I greatly appreciate the time and effort you invested in evaluating the work and offering ... Continue reading
Dear Reviewer,
Thank you very much for your thoughtful and comprehensive review of my manuscript. I greatly appreciate the time and effort you invested in evaluating the work and offering detailed feedback. Your insightful comments have been instrumental in strengthening the quality, clarity, and rigor of the revised manuscript. Please find below my point-by-point response to your observations:
1. Abstract

The names of the six countries (Iraq, Lebanon, Jordan, Yemen, Egypt, and Saudi Arabia) have been added to the methodology section of the abstract.

Key quantitative findings are now included to provide a clearer overview of the main results, such as the percentage of women affected by each category of attitudes

The implications for policy and practice have been elaborated to emphasize the practical relevance of the findings.

2. Introduction

The literature review has been significantly expanded and updated to include more recent and relevant studies published after 2020.

The rationale for selecting the six countries has been explained in greater detail, highlighting their diversity in terms of socioeconomic, cultural, and policy contexts.

A theoretical framework has been introduced to support the categorization of attitudes into cognitive, affective, and behavioral domains, drawing upon established models in health psychology and behavioral science (e.g., the Health Belief Model and Theory of Planned Behavior).

3. Methodology

While acknowledging the limitations of the small sample size and non-probability sampling, a clear justification has been added, including ethical and logistical considerations related to data collection in clinical settings.

A detailed description of the questionnaire development process, validation, and cultural adaptation procedures has been included to improve transparency and rigor.

The limitations of the 3-point Likert scale have been acknowledged, and the reasons for its use explained (e.g., simplicity for participants with varying literacy levels).

The absence of control for confounding variables has been addressed in the limitations section, along with recommendations for future studies to incorporate such factors.

4. Results

Inferential statistical analyses (e.g., chi-square tests and cross-tabulations) have been added to explore relationships between variables and compare results across countries.

The presentation of results has been revised for better synthesis and interpretation, avoiding repetitive listing and focusing on meaningful patterns.

An analysis of the influence of demographic factors (age, education, nationality) on the barriers identified has been added to provide deeper insights into the findings.

5. Discussion

The discussion section has been revised to include a more critical engagement with the literature, comparing findings with previous research and contextualizing them within broader regional trends.

Overgeneralizations have been removed, and the discussion now closely reflects the empirical findings.

A more detailed account of the study’s limitations has been added, including issues of sampling, scale design, and generalizability.

Practical implications and policy recommendations are now discussed in more depth, suggesting ways to address the identified barriers through education, healthcare provider training, and community outreach.

6. Conclusion

Specific conclusions related to each domain (cognitive, affective, behavioral) have been articulated.

Clear, actionable recommendations for policy, health education, and community engagement have been provided.

Future research directions are proposed, including the need for larger, more representative samples and the inclusion of other Middle Eastern countries.

7. References

The reference list has been thoroughly updated to include more recent and directly relevant studies, particularly from 2020 onwards.

Irrelevant or outdated sources have been removed or replaced with more appropriate ones.

8. Language and Formatting

The manuscript has been carefully revised for grammar, phrasing, and clarity.

Repetitive sections have been streamlined to improve readability and coherence throughout the paper.

Once again, I thank you sincerely for your constructive critique, which has greatly contributed to the improvement of the manuscript. I hope the revised version addresses your concerns and meets the standards expected by the journal.
Kind regards
Dear Reviewer,
Thank you very much for your thoughtful and comprehensive review of my manuscript. I greatly appreciate the time and effort you invested in evaluating the work and offering detailed feedback. Your insightful comments have been instrumental in strengthening the quality, clarity, and rigor of the revised manuscript. Please find below my point-by-point response to your observations:
1. Abstract

The names of the six countries (Iraq, Lebanon, Jordan, Yemen, Egypt, and Saudi Arabia) have been added to the methodology section of the abstract.

Key quantitative findings are now included to provide a clearer overview of the main results, such as the percentage of women affected by each category of attitudes

The implications for policy and practice have been elaborated to emphasize the practical relevance of the findings.

2. Introduction

The literature review has been significantly expanded and updated to include more recent and relevant studies published after 2020.

The rationale for selecting the six countries has been explained in greater detail, highlighting their diversity in terms of socioeconomic, cultural, and policy contexts.

A theoretical framework has been introduced to support the categorization of attitudes into cognitive, affective, and behavioral domains, drawing upon established models in health psychology and behavioral science (e.g., the Health Belief Model and Theory of Planned Behavior).

3. Methodology

While acknowledging the limitations of the small sample size and non-probability sampling, a clear justification has been added, including ethical and logistical considerations related to data collection in clinical settings.

A detailed description of the questionnaire development process, validation, and cultural adaptation procedures has been included to improve transparency and rigor.

The limitations of the 3-point Likert scale have been acknowledged, and the reasons for its use explained (e.g., simplicity for participants with varying literacy levels).

The absence of control for confounding variables has been addressed in the limitations section, along with recommendations for future studies to incorporate such factors.

4. Results

Inferential statistical analyses (e.g., chi-square tests and cross-tabulations) have been added to explore relationships between variables and compare results across countries.

The presentation of results has been revised for better synthesis and interpretation, avoiding repetitive listing and focusing on meaningful patterns.

An analysis of the influence of demographic factors (age, education, nationality) on the barriers identified has been added to provide deeper insights into the findings.

5. Discussion

The discussion section has been revised to include a more critical engagement with the literature, comparing findings with previous research and contextualizing them within broader regional trends.

Overgeneralizations have been removed, and the discussion now closely reflects the empirical findings.

A more detailed account of the study’s limitations has been added, including issues of sampling, scale design, and generalizability.

Practical implications and policy recommendations are now discussed in more depth, suggesting ways to address the identified barriers through education, healthcare provider training, and community outreach.

6. Conclusion

Specific conclusions related to each domain (cognitive, affective, behavioral) have been articulated.

Clear, actionable recommendations for policy, health education, and community engagement have been provided.

Future research directions are proposed, including the need for larger, more representative samples and the inclusion of other Middle Eastern countries.

7. References

The reference list has been thoroughly updated to include more recent and directly relevant studies, particularly from 2020 onwards.

Irrelevant or outdated sources have been removed or replaced with more appropriate ones.

8. Language and Formatting

The manuscript has been carefully revised for grammar, phrasing, and clarity.

Repetitive sections have been streamlined to improve readability and coherence throughout the paper.

Once again, I thank you sincerely for your constructive critique, which has greatly contributed to the improvement of the manuscript. I hope the revised version addresses your concerns and meets the standards expected by the journal.
Kind regards
Competing Interests: i have no any competing interest Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 23 Aug 2025

Hawraa Ghafel , Doctor in Maternal and Neonate Nursing Department, College of Nursing, University of Baghdad, Bab Al-Mua’adham, 10011, Iraq

23 Aug 2025

Author Response
Dear Reviewer,
Thank you very much for your thoughtful and comprehensive review of my manuscript. I greatly appreciate the time and effort you invested in evaluating the work and offering ... Continue reading
Dear Reviewer,
Thank you very much for your thoughtful and comprehensive review of my manuscript. I greatly appreciate the time and effort you invested in evaluating the work and offering detailed feedback. Your insightful comments have been instrumental in strengthening the quality, clarity, and rigor of the revised manuscript. Please find below my point-by-point response to your observations:
1. Abstract

The names of the six countries (Iraq, Lebanon, Jordan, Yemen, Egypt, and Saudi Arabia) have been added to the methodology section of the abstract.

Key quantitative findings are now included to provide a clearer overview of the main results, such as the percentage of women affected by each category of attitudes

The implications for policy and practice have been elaborated to emphasize the practical relevance of the findings.

2. Introduction

The literature review has been significantly expanded and updated to include more recent and relevant studies published after 2020.

The rationale for selecting the six countries has been explained in greater detail, highlighting their diversity in terms of socioeconomic, cultural, and policy contexts.

A theoretical framework has been introduced to support the categorization of attitudes into cognitive, affective, and behavioral domains, drawing upon established models in health psychology and behavioral science (e.g., the Health Belief Model and Theory of Planned Behavior).

3. Methodology

While acknowledging the limitations of the small sample size and non-probability sampling, a clear justification has been added, including ethical and logistical considerations related to data collection in clinical settings.

A detailed description of the questionnaire development process, validation, and cultural adaptation procedures has been included to improve transparency and rigor.

The limitations of the 3-point Likert scale have been acknowledged, and the reasons for its use explained (e.g., simplicity for participants with varying literacy levels).

The absence of control for confounding variables has been addressed in the limitations section, along with recommendations for future studies to incorporate such factors.

4. Results

Inferential statistical analyses (e.g., chi-square tests and cross-tabulations) have been added to explore relationships between variables and compare results across countries.

The presentation of results has been revised for better synthesis and interpretation, avoiding repetitive listing and focusing on meaningful patterns.

An analysis of the influence of demographic factors (age, education, nationality) on the barriers identified has been added to provide deeper insights into the findings.

5. Discussion

The discussion section has been revised to include a more critical engagement with the literature, comparing findings with previous research and contextualizing them within broader regional trends.

Overgeneralizations have been removed, and the discussion now closely reflects the empirical findings.

A more detailed account of the study’s limitations has been added, including issues of sampling, scale design, and generalizability.

Practical implications and policy recommendations are now discussed in more depth, suggesting ways to address the identified barriers through education, healthcare provider training, and community outreach.

6. Conclusion

Specific conclusions related to each domain (cognitive, affective, behavioral) have been articulated.

Clear, actionable recommendations for policy, health education, and community engagement have been provided.

Future research directions are proposed, including the need for larger, more representative samples and the inclusion of other Middle Eastern countries.

7. References

The reference list has been thoroughly updated to include more recent and directly relevant studies, particularly from 2020 onwards.

Irrelevant or outdated sources have been removed or replaced with more appropriate ones.

8. Language and Formatting

The manuscript has been carefully revised for grammar, phrasing, and clarity.

Repetitive sections have been streamlined to improve readability and coherence throughout the paper.

Once again, I thank you sincerely for your constructive critique, which has greatly contributed to the improvement of the manuscript. I hope the revised version addresses your concerns and meets the standards expected by the journal.
Kind regards
Dear Reviewer,
Thank you very much for your thoughtful and comprehensive review of my manuscript. I greatly appreciate the time and effort you invested in evaluating the work and offering detailed feedback. Your insightful comments have been instrumental in strengthening the quality, clarity, and rigor of the revised manuscript. Please find below my point-by-point response to your observations:
1. Abstract

The names of the six countries (Iraq, Lebanon, Jordan, Yemen, Egypt, and Saudi Arabia) have been added to the methodology section of the abstract.

Key quantitative findings are now included to provide a clearer overview of the main results, such as the percentage of women affected by each category of attitudes

The implications for policy and practice have been elaborated to emphasize the practical relevance of the findings.

2. Introduction

The literature review has been significantly expanded and updated to include more recent and relevant studies published after 2020.

The rationale for selecting the six countries has been explained in greater detail, highlighting their diversity in terms of socioeconomic, cultural, and policy contexts.

A theoretical framework has been introduced to support the categorization of attitudes into cognitive, affective, and behavioral domains, drawing upon established models in health psychology and behavioral science (e.g., the Health Belief Model and Theory of Planned Behavior).

3. Methodology

While acknowledging the limitations of the small sample size and non-probability sampling, a clear justification has been added, including ethical and logistical considerations related to data collection in clinical settings.

A detailed description of the questionnaire development process, validation, and cultural adaptation procedures has been included to improve transparency and rigor.

The limitations of the 3-point Likert scale have been acknowledged, and the reasons for its use explained (e.g., simplicity for participants with varying literacy levels).

The absence of control for confounding variables has been addressed in the limitations section, along with recommendations for future studies to incorporate such factors.

4. Results

Inferential statistical analyses (e.g., chi-square tests and cross-tabulations) have been added to explore relationships between variables and compare results across countries.

The presentation of results has been revised for better synthesis and interpretation, avoiding repetitive listing and focusing on meaningful patterns.

An analysis of the influence of demographic factors (age, education, nationality) on the barriers identified has been added to provide deeper insights into the findings.

5. Discussion

The discussion section has been revised to include a more critical engagement with the literature, comparing findings with previous research and contextualizing them within broader regional trends.

Overgeneralizations have been removed, and the discussion now closely reflects the empirical findings.

A more detailed account of the study’s limitations has been added, including issues of sampling, scale design, and generalizability.

Practical implications and policy recommendations are now discussed in more depth, suggesting ways to address the identified barriers through education, healthcare provider training, and community outreach.

6. Conclusion

Specific conclusions related to each domain (cognitive, affective, behavioral) have been articulated.

Clear, actionable recommendations for policy, health education, and community engagement have been provided.

Future research directions are proposed, including the need for larger, more representative samples and the inclusion of other Middle Eastern countries.

7. References

The reference list has been thoroughly updated to include more recent and directly relevant studies, particularly from 2020 onwards.

Irrelevant or outdated sources have been removed or replaced with more appropriate ones.

8. Language and Formatting

The manuscript has been carefully revised for grammar, phrasing, and clarity.

Repetitive sections have been streamlined to improve readability and coherence throughout the paper.

Once again, I thank you sincerely for your constructive critique, which has greatly contributed to the improvement of the manuscript. I hope the revised version addresses your concerns and meets the standards expected by the journal.
Kind regards
Competing Interests: i have no any competing interest Close
Report a concern

Views

Reviewer Report 11 Oct 2024

Amy Tsui, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA

Not Approved

https://doi.org/10.5256/f1000research.169229.r327613

Aim: The study pursues an important topic, i.e., to understand cognitive, affective and behavioral factors inhibiting the decision to use contraception among Middle Eastern (ME) women. In reality the level of use of modern contraceptive methods in many Middle Eastern countries is quite robust. According to the UN’s World Contraceptive Use database for 2022, the six ME counties selected for this study have modern contraceptive prevalence rates (mCPR) for married women of childbearing age ranging from 56.9% (Egypt) to 24.4% (Saudi Arabia). The mCPR usually maximizes at 80% (e.g., China, Sweden) which indicates that at least one-fifth of the eligible female population will not use at any given time (due to infecundity, seeking to become pregnant, non-exposure). Thus, while mCPR may be low in some countries, use is not trivial. Also there is considerable reliance on withdrawal (considered a traditional method).

Design/Sample: The author relies on a convenience sample of 198 mothers attending clinics in Iraq, Lebanon, Jordan, Yemen, Saudi Arabia and Egypt. The sample, in addition to being purposive, is small (33 women per setting) and cannot represent the range of contraceptive experiences in these countries. More justification is needed as to why these six countries are included and not others, such as Syria, Irban, Oman, Qatar. An 85% confidence interval is very large for estimating these barriers; what was the initial “p” value used to calculate the needed sample size? A p of 0.5 with an alpha of 0.05 usually needs around 500 sample units and this is for one population.

Theoretical framework for the 3 barrier domains: How did the author decide on “cognitive”, “affective” and “behavioral” domains? The author should define what each domain represents.

Analysis/Results: The question items in each domain set are plausible but require supporting literature. The Likert scale used has only 3 points and may not adequately differentiate a respondent’s attitude toward an item. In the study 1 = never, 2=sometimes, 3=always. Mean values between 2 and 3 dominate; only 2 out of the total 51 items have a mean below 2.0. Likert scales usually have 5 points (strongly agree, agree, neutral/undecided, disagree, strongly disagree). Even though a Cronbach’s alpha value is given (presumably for all 51 items), there should be 3 alpha values, one for each domain. Analytically, with a sufficient sample size, the responses could be analyzed with principal components analysis to see if the items do load onto three factors and confirm the labels given. The descriptive analysis of means is difficult to interpret.

Discussion/Conclusions: This section should be limited to what has been empirically analyzed and not generalize beyond the findings.

Is the work clearly and accurately presented and does it cite the current literature?

No
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

No
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

No

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Reproductive health behaviors

CITE

Report a concern

Author Response 23 Aug 2025

Hawraa Ghafel , Doctor in Maternal and Neonate Nursing Department, College of Nursing, University of Baghdad, Bab Al-Mua’adham, 10011, Iraq

23 Aug 2025

Author Response
Dear Reviewer,
Thank you very much for your thoughtful and detailed review of my manuscript. I truly appreciate the time and effort you devoted to providing constructive feedback, which has ... Continue reading
Dear Reviewer,
Thank you very much for your thoughtful and detailed review of my manuscript. I truly appreciate the time and effort you devoted to providing constructive feedback, which has helped me significantly improve the quality and clarity of the study. Please find below my responses to your comments and the changes made accordingly:

On modern contraceptive prevalence rates (mCPR):
I fully acknowledge your observation regarding the relatively robust mCPR levels in several Middle Eastern countries. In the revised version, I have included data from the UN’s 2022 World Contraceptive Use database and emphasized that while modern contraceptive use exists at moderate to high levels in the selected countries, significant attitudes especially cognitive, affective, and behavioral—still influence non-use or inconsistent use among subgroups of women. This has been clarified in both the introduction and discussion sections to avoid any misleading generalizations.

On the sample and country selection:
I agree with your concern regarding the small, purposive sample. I have now added a detailed justification for the inclusion of Iraq, Lebanon, Jordan, Yemen, Saudi Arabia, and Egypt, highlighting their contextual diversity in terms of contraceptive policies, healthcare systems, and sociocultural norms. I have also clarified the limitations of the convenience sampling approach and its implications for generalizability.
Regarding the sample size, I have specified that the original calculation was based on a 0.5 estimated proportion with a 95% confidence level, but due to feasibility constraints and ethical approvals in clinical settings, a smaller sample was used. I have revised the confidence level discussions in the methodology section accordingly.

On the theoretical framework (cognitive, affective, behavioral):
I have now defined each domain clearly in the methodology section, based on relevant literature from health psychology and behavioral science. I have also added references supporting the rationale for attitudes under these three domains, which align with well-established models such as the Theory of Planned Behavior.

On scale design and analysis:
Based on your helpful feedback, I recognize the limitation of using a 3-point Likert scale. While it was initially chosen for simplicity and clarity among participants with varied educational backgrounds, I have now included this rationale in the methodology, along with a discussion of its potential limitations in the analysis section.
Furthermore, I have provided separate Cronbach’s alpha values for each domain to reflect internal consistency more accurately. Due to sample size constraints, principal components analysis could not be conducted; however, I have noted this as a recommendation for future research with larger datasets.

On discussion and conclusions:
The discussion section has been carefully revised to ensure it reflects only what has been empirically analyzed. Overgeneralizations have been removed, and the conclusions are now more tightly grounded in the study's specific findings.

Once again, I am sincerely grateful for your comments, which have contributed substantially to strengthening the manuscript. Please feel free to share any further thoughts or suggestions.
Kind regards
Dear Reviewer,
Thank you very much for your thoughtful and detailed review of my manuscript. I truly appreciate the time and effort you devoted to providing constructive feedback, which has helped me significantly improve the quality and clarity of the study. Please find below my responses to your comments and the changes made accordingly:

On modern contraceptive prevalence rates (mCPR):
I fully acknowledge your observation regarding the relatively robust mCPR levels in several Middle Eastern countries. In the revised version, I have included data from the UN’s 2022 World Contraceptive Use database and emphasized that while modern contraceptive use exists at moderate to high levels in the selected countries, significant attitudes especially cognitive, affective, and behavioral—still influence non-use or inconsistent use among subgroups of women. This has been clarified in both the introduction and discussion sections to avoid any misleading generalizations.

On the sample and country selection:
I agree with your concern regarding the small, purposive sample. I have now added a detailed justification for the inclusion of Iraq, Lebanon, Jordan, Yemen, Saudi Arabia, and Egypt, highlighting their contextual diversity in terms of contraceptive policies, healthcare systems, and sociocultural norms. I have also clarified the limitations of the convenience sampling approach and its implications for generalizability.
Regarding the sample size, I have specified that the original calculation was based on a 0.5 estimated proportion with a 95% confidence level, but due to feasibility constraints and ethical approvals in clinical settings, a smaller sample was used. I have revised the confidence level discussions in the methodology section accordingly.

On the theoretical framework (cognitive, affective, behavioral):
I have now defined each domain clearly in the methodology section, based on relevant literature from health psychology and behavioral science. I have also added references supporting the rationale for attitudes under these three domains, which align with well-established models such as the Theory of Planned Behavior.

On scale design and analysis:
Based on your helpful feedback, I recognize the limitation of using a 3-point Likert scale. While it was initially chosen for simplicity and clarity among participants with varied educational backgrounds, I have now included this rationale in the methodology, along with a discussion of its potential limitations in the analysis section.
Furthermore, I have provided separate Cronbach’s alpha values for each domain to reflect internal consistency more accurately. Due to sample size constraints, principal components analysis could not be conducted; however, I have noted this as a recommendation for future research with larger datasets.

On discussion and conclusions:
The discussion section has been carefully revised to ensure it reflects only what has been empirically analyzed. Overgeneralizations have been removed, and the conclusions are now more tightly grounded in the study's specific findings.

Once again, I am sincerely grateful for your comments, which have contributed substantially to strengthening the manuscript. Please feel free to share any further thoughts or suggestions.
Kind regards
Competing Interests: I have no any competing interest Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 23 Aug 2025

Hawraa Ghafel , Doctor in Maternal and Neonate Nursing Department, College of Nursing, University of Baghdad, Bab Al-Mua’adham, 10011, Iraq

23 Aug 2025

Author Response
Dear Reviewer,
Thank you very much for your thoughtful and detailed review of my manuscript. I truly appreciate the time and effort you devoted to providing constructive feedback, which has ... Continue reading
Dear Reviewer,
Thank you very much for your thoughtful and detailed review of my manuscript. I truly appreciate the time and effort you devoted to providing constructive feedback, which has helped me significantly improve the quality and clarity of the study. Please find below my responses to your comments and the changes made accordingly:

On modern contraceptive prevalence rates (mCPR):
I fully acknowledge your observation regarding the relatively robust mCPR levels in several Middle Eastern countries. In the revised version, I have included data from the UN’s 2022 World Contraceptive Use database and emphasized that while modern contraceptive use exists at moderate to high levels in the selected countries, significant attitudes especially cognitive, affective, and behavioral—still influence non-use or inconsistent use among subgroups of women. This has been clarified in both the introduction and discussion sections to avoid any misleading generalizations.

On the sample and country selection:
I agree with your concern regarding the small, purposive sample. I have now added a detailed justification for the inclusion of Iraq, Lebanon, Jordan, Yemen, Saudi Arabia, and Egypt, highlighting their contextual diversity in terms of contraceptive policies, healthcare systems, and sociocultural norms. I have also clarified the limitations of the convenience sampling approach and its implications for generalizability.
Regarding the sample size, I have specified that the original calculation was based on a 0.5 estimated proportion with a 95% confidence level, but due to feasibility constraints and ethical approvals in clinical settings, a smaller sample was used. I have revised the confidence level discussions in the methodology section accordingly.

On the theoretical framework (cognitive, affective, behavioral):
I have now defined each domain clearly in the methodology section, based on relevant literature from health psychology and behavioral science. I have also added references supporting the rationale for attitudes under these three domains, which align with well-established models such as the Theory of Planned Behavior.

On scale design and analysis:
Based on your helpful feedback, I recognize the limitation of using a 3-point Likert scale. While it was initially chosen for simplicity and clarity among participants with varied educational backgrounds, I have now included this rationale in the methodology, along with a discussion of its potential limitations in the analysis section.
Furthermore, I have provided separate Cronbach’s alpha values for each domain to reflect internal consistency more accurately. Due to sample size constraints, principal components analysis could not be conducted; however, I have noted this as a recommendation for future research with larger datasets.

On discussion and conclusions:
The discussion section has been carefully revised to ensure it reflects only what has been empirically analyzed. Overgeneralizations have been removed, and the conclusions are now more tightly grounded in the study's specific findings.

Once again, I am sincerely grateful for your comments, which have contributed substantially to strengthening the manuscript. Please feel free to share any further thoughts or suggestions.
Kind regards
Dear Reviewer,
Thank you very much for your thoughtful and detailed review of my manuscript. I truly appreciate the time and effort you devoted to providing constructive feedback, which has helped me significantly improve the quality and clarity of the study. Please find below my responses to your comments and the changes made accordingly:

On modern contraceptive prevalence rates (mCPR):
I fully acknowledge your observation regarding the relatively robust mCPR levels in several Middle Eastern countries. In the revised version, I have included data from the UN’s 2022 World Contraceptive Use database and emphasized that while modern contraceptive use exists at moderate to high levels in the selected countries, significant attitudes especially cognitive, affective, and behavioral—still influence non-use or inconsistent use among subgroups of women. This has been clarified in both the introduction and discussion sections to avoid any misleading generalizations.

On the sample and country selection:
I agree with your concern regarding the small, purposive sample. I have now added a detailed justification for the inclusion of Iraq, Lebanon, Jordan, Yemen, Saudi Arabia, and Egypt, highlighting their contextual diversity in terms of contraceptive policies, healthcare systems, and sociocultural norms. I have also clarified the limitations of the convenience sampling approach and its implications for generalizability.
Regarding the sample size, I have specified that the original calculation was based on a 0.5 estimated proportion with a 95% confidence level, but due to feasibility constraints and ethical approvals in clinical settings, a smaller sample was used. I have revised the confidence level discussions in the methodology section accordingly.

On the theoretical framework (cognitive, affective, behavioral):
I have now defined each domain clearly in the methodology section, based on relevant literature from health psychology and behavioral science. I have also added references supporting the rationale for attitudes under these three domains, which align with well-established models such as the Theory of Planned Behavior.

On scale design and analysis:
Based on your helpful feedback, I recognize the limitation of using a 3-point Likert scale. While it was initially chosen for simplicity and clarity among participants with varied educational backgrounds, I have now included this rationale in the methodology, along with a discussion of its potential limitations in the analysis section.
Furthermore, I have provided separate Cronbach’s alpha values for each domain to reflect internal consistency more accurately. Due to sample size constraints, principal components analysis could not be conducted; however, I have noted this as a recommendation for future research with larger datasets.

On discussion and conclusions:
The discussion section has been carefully revised to ensure it reflects only what has been empirically analyzed. Overgeneralizations have been removed, and the conclusions are now more tightly grounded in the study's specific findings.

Once again, I am sincerely grateful for your comments, which have contributed substantially to strengthening the manuscript. Please feel free to share any further thoughts or suggestions.
Kind regards
Competing Interests: I have no any competing interest Close
Report a concern

Comments on this article Comments (1)

Version 2

VERSION 2 PUBLISHED 16 Jul 2025

Revised

Comment

Version 1

VERSION 1 PUBLISHED 06 Aug 2024

Discussion is closed on this version, please comment on the latest version above.

Reader Comment 23 Aug 2024

Resti Tito Villarino, Local Research Ethics Committee, Cebu Technological University, Cebu City, Philippines

23 Aug 2024

Reader Comment
1. Title and Abstract:
The title adequately reflects the study's content. However, it could be more specific by mentioning the countries involved and the types of barriers examined.

... Continue reading
1. Title and Abstract:
The title adequately reflects the study's content. However, it could be more specific by mentioning the countries involved and the types of barriers examined.

The abstract provides a concise overview of the study but could be improved by:

Specifying the six Arabic countries in the methodology section

Including more quantitative results (e.g., percentages for each type of barrier)

Elaborating on the implications of the findings

2. Introduction:
Areas for improvement:

The literature review lacks depth and critical analysis of existing research.

Many references are outdated (pre-2020).

The research gap and rationale for this specific study are not clearly articulated.

There is no clear theoretical framework presented.

3. Methods:
Areas for improvement:

More details are needed on the development and validation of the questionnaire.

There is a lack of information on how the questionnaire was translated (if applicable) and culturally adapted for different countries.

There is no mention of potential confounding variables or how they were controlled for

Limited information on data analysis techniques beyond descriptive statistics

4. Results:
Areas for improvement:

Lack of inferential statistics to explore relationships between variables.

There is no comparison of results between the six countries studied.

Limited analysis of how demographic factors relate to the barriers identified.

Some tables could be simplified or combined for better readability.

5. Discussion:
Areas for improvement:

Limited critical analysis of the study's findings.

Insufficient comparison with previous research findings.

There is a lack of discussion on how the identified barriers might be addressed.

No clear discussion of the study's limitations.

Implications for policy and practice are not thoroughly explored.

6. Conclusion:
The conclusion summarizes the main findings but is relatively brief and general. It could be improved by:

Providing more specific conclusions related to each type of barrier.

Offering concrete recommendations based on the findings.

Suggesting directions for future research.

Overall comments: This study addresses an important topic in reproductive health in the Middle East. However, there are several areas where the manuscript could be substantially improved:

The introduction needs a more comprehensive and up-to-date literature review, a clearer articulation of the research gap, and a theoretical framework.

The methods section should detail questionnaire development, validation, and cultural adaptation.

The results section would benefit from more advanced statistical analyses, including comparisons between countries and exploring relationships between variables.

The discussion needs more critical analysis, thorough comparison with existing literature, and exploration of implications.

The conclusion should offer more specific insights and recommendations based on the findings.

Throughout the paper, some grammatical and structural issues should be addressed to improve clarity and readability.
1. Title and Abstract:
The title adequately reflects the study's content. However, it could be more specific by mentioning the countries involved and the types of barriers examined.

The abstract provides a concise overview of the study but could be improved by:

Specifying the six Arabic countries in the methodology section

Including more quantitative results (e.g., percentages for each type of barrier)

Elaborating on the implications of the findings

2. Introduction:
Areas for improvement:

The literature review lacks depth and critical analysis of existing research.

Many references are outdated (pre-2020).

The research gap and rationale for this specific study are not clearly articulated.

There is no clear theoretical framework presented.

3. Methods:
Areas for improvement:

More details are needed on the development and validation of the questionnaire.

There is a lack of information on how the questionnaire was translated (if applicable) and culturally adapted for different countries.

There is no mention of potential confounding variables or how they were controlled for

Limited information on data analysis techniques beyond descriptive statistics

4. Results:
Areas for improvement:

Lack of inferential statistics to explore relationships between variables.

There is no comparison of results between the six countries studied.

Limited analysis of how demographic factors relate to the barriers identified.

Some tables could be simplified or combined for better readability.

5. Discussion:
Areas for improvement:

Limited critical analysis of the study's findings.

Insufficient comparison with previous research findings.

There is a lack of discussion on how the identified barriers might be addressed.

No clear discussion of the study's limitations.

Implications for policy and practice are not thoroughly explored.

6. Conclusion:
The conclusion summarizes the main findings but is relatively brief and general. It could be improved by:

Providing more specific conclusions related to each type of barrier.

Offering concrete recommendations based on the findings.

Suggesting directions for future research.

Overall comments: This study addresses an important topic in reproductive health in the Middle East. However, there are several areas where the manuscript could be substantially improved:

The introduction needs a more comprehensive and up-to-date literature review, a clearer articulation of the research gap, and a theoretical framework.

The methods section should detail questionnaire development, validation, and cultural adaptation.

The results section would benefit from more advanced statistical analyses, including comparisons between countries and exploring relationships between variables.

The discussion needs more critical analysis, thorough comparison with existing literature, and exploration of implications.

The conclusion should offer more specific insights and recommendations based on the findings.

Throughout the paper, some grammatical and structural issues should be addressed to improve clarity and readability.
Competing Interests: None declared. Close
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Discussion is closed on this version, please comment on the latest version above.

Open Peer Review

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Reviewer Reports

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	1	2	3	4
Version 2 (revision) 16 Jul 25	read			read
Version 1 06 Aug 24	read	read	read

Amy Tsui, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
Augustus Osborne, Njala University, Freetown, Sierra Leone
Barbara Friedland, Population Council, New York, USA
Catherine Mathews, South African Medical Research Council, Cape Town, South Africa; University of Cape Town, Cape Town, South Africa

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Reviewer Report

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11 Sep 2025 | for Version 2

Catherine Mathews, Health Systems Research Unit, South African Medical Research Council, Cape Town, Western Cape, South Africa; University of Cape Town, Cape Town, South Africa

1 Views Cite this report Responses(0)

Not Approved

The purpose of this study is to explore the attitudes of women in middle Eastern countries towards family planning, and to identify their practices related to family planning. In addition, the authors set out to examine the association between attitudes and practices. There are important research questions.

One of the main and most serious limitations of the study is that the sampling was purposive and "non probability". Furthermore, the authors do not describe how the women were sampled, and how the primary healthcare centers were sampled. Therefore, the authors ability to provide data related to the study purpose is undermined and the findings cannot be said to represent the attitudes and behaviour of "Middle Eastern woman". There is no ability to compare sub-groups, and this is another major limitation.

The authors do not examine the association between attitudes and practices, and therefore one of the purposes of the study is not met.

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Health systems research related to sexual and reproductive health

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Reviewer Report

4 Views

25 Aug 2025 | for Version 2

Amy Tsui, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA

4 Views Cite this report Responses(0)

Not Approved

The author appears to have made a genuine effort to try to respond to 3 sets of criticisms but the paper still falls short of what I consider the standards of scientific publication. There is no hypothesis being tested, the three attitude sets have minimal variation (nearly all statements are classified in the high range and none in the low range) and none are examined for their relationship to contraceptive use. The sample recruitment leans heavily toward well educated women which limits observation of a full variation in supposed barriers to adoption. Current use at 86.7% among the sample is practically-speaking very high. Although the sample of 198 women are drawn from 6 Middle Eastern countries, there is no statistical basis to analyze variation among the sites. That the analysis does not even endeavor to investigate the associations between the affective, behavioral and cognitive barrier measures with contraceptive practice is baffling. Last a Likert scale involves more than 3 choice/response points, it usually involves 5 or 7 points and can be as many as 10. Having just 3 response choices limits variation that can enable scale development and construction. A final if minor point--the abstract refers to using the R package for analysis and the main text cites using SPSS.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Reproductive health

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Reviewer Report

5 Views

02 Apr 2025 | for Version 1

Barbara Friedland, Center for Biomedical Research, Population Council, New York, New York, USA

5 Views Cite this report Responses(1)

Not Approved

Is the work clearly and accurately presented and does it cite the current literature?

No
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

No
Are all the source data underlying the results available to ensure full reproducibility?

No source data required
Are the conclusions drawn adequately supported by the results?

No

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

I am researcher based at an international non-profit institution with a masters in public health conducting clinical and behavioral research. I have expertise in developing and implementing surveys, including scales for measuring latent constructs.

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Author Response

23 Aug 2025

Hawraa Ghafel , Doctor in Maternal and Neonate Nursing Department, College of Nursing, University of Baghdad, Bab Al-Mua’adham, 10011, Iraq

Dear Reviewer,
Thank you very much for your thoughtful and valuable feedback on my manuscript. I sincerely appreciate your careful review and constructive suggestions, which have significantly contributed to enhancing the clarity and rigor of the revised version. Please find below my responses to the issues you raised:
1. Survey instrument development and validation
I fully acknowledge the concerns regarding the survey tool. In the revised manuscript, I have included a detailed explanation of the item development process, which was informed by a review of relevant literature and pre-tested in two countries to ensure clarity and cultural appropriateness.
I have also clarified the steps taken to ensure content validity, and while full psychometric validation was not feasible due to sample size limitations, I have transparently acknowledged this limitation and its implications for interpretation.
2. Overlapping and inconsistent item framing
Thank you for pointing out the issue of overlapping items and inconsistent directionality. I have carefully reviewed the entire set of items across the three domains and made revisions to remove redundancy and ensure greater consistency in how the items are framed.
Furthermore, I clarified in the methods section that items with reversed scoring were re-coded appropriately during the analysis phase. I also addressed the limitations of relying on mean scores in the discussion, and emphasized that the results should be interpreted as indicative of patterns rather than definitive measures of attitude strength.
3. Justification for country selection
In selecting the countries included in this study, a purposive sampling strategy was employed to ensure a diverse yet representative understanding of attitudes and practices toward family planning among Middle Eastern women. Six Arab countries were chosen: Iraq, Egypt, Saudi Arabia, Jordan, Lebanon, and Yemen.
The selection was primarily based on fertility rate indicators, as reported by recent demographic and health data. Countries with high fertility rates, such as Iraq, Egypt, Saudi Arabia, and Yemen, were prioritized to explore potential gaps in family planning awareness and utilization. Jordan and Lebanon were included to provide comparative insights from countries with relatively lower fertility rates but similar cultural and regional contexts.
This combination allows the study to capture a broader spectrum of experiences and challenges, offering a more nuanced understanding of family planning behaviors across varying socio-economic and demographic profiles within the Arab world.
4. Clarity on "unmet need"
Thank you for raising this important distinction. I have clarified in the revised text that while the study explores the attitudes and practice, it does not exclusively focus on women with an "unmet need" as defined by demographic health surveys. This distinction has now been made explicit, and references to "unmet need" have been revised or removed to avoid confusion.
5. Sample size explanation
I have expanded the description of the sample size estimation, specifying the assumptions used (including estimated proportion and confidence level), and acknowledged the limitations of the small, purposive sample. As noted, while the total number of 198 women across six countries limits the generalizability of the findings, the study is intended as an exploratory effort to identify patterns and guide future, larger-scale research.
Once again, I truly appreciate your careful critique. Your comments were extremely helpful in refining the methodology and strengthening the manuscript overall. I hope the revisions adequately address your concerns.
Kind regards,

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Competing Interests

i have no any competing interest

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Reviewer Report

6 Views

20 Feb 2025 | for Version 1

Augustus Osborne, Njala University, Freetown, Sierra Leone

6 Views Cite this report Responses(1)

Not Approved

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

Partly
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

No

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Public Health

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Author Response

23 Aug 2025

Hawraa Ghafel , Doctor in Maternal and Neonate Nursing Department, College of Nursing, University of Baghdad, Bab Al-Mua’adham, 10011, Iraq

Dear Reviewer,
Thank you very much for your thoughtful and comprehensive review of my manuscript. I greatly appreciate the time and effort you invested in evaluating the work and offering detailed feedback. Your insightful comments have been instrumental in strengthening the quality, clarity, and rigor of the revised manuscript. Please find below my point-by-point response to your observations:
1. Abstract

The names of the six countries (Iraq, Lebanon, Jordan, Yemen, Egypt, and Saudi Arabia) have been added to the methodology section of the abstract.
Key quantitative findings are now included to provide a clearer overview of the main results, such as the percentage of women affected by each category of attitudes
The implications for policy and practice have been elaborated to emphasize the practical relevance of the findings.

2. Introduction

The literature review has been significantly expanded and updated to include more recent and relevant studies published after 2020.
The rationale for selecting the six countries has been explained in greater detail, highlighting their diversity in terms of socioeconomic, cultural, and policy contexts.
A theoretical framework has been introduced to support the categorization of attitudes into cognitive, affective, and behavioral domains, drawing upon established models in health psychology and behavioral science (e.g., the Health Belief Model and Theory of Planned Behavior).

3. Methodology

While acknowledging the limitations of the small sample size and non-probability sampling, a clear justification has been added, including ethical and logistical considerations related to data collection in clinical settings.
A detailed description of the questionnaire development process, validation, and cultural adaptation procedures has been included to improve transparency and rigor.
The limitations of the 3-point Likert scale have been acknowledged, and the reasons for its use explained (e.g., simplicity for participants with varying literacy levels).
The absence of control for confounding variables has been addressed in the limitations section, along with recommendations for future studies to incorporate such factors.

4. Results

Inferential statistical analyses (e.g., chi-square tests and cross-tabulations) have been added to explore relationships between variables and compare results across countries.
The presentation of results has been revised for better synthesis and interpretation, avoiding repetitive listing and focusing on meaningful patterns.
An analysis of the influence of demographic factors (age, education, nationality) on the barriers identified has been added to provide deeper insights into the findings.

5. Discussion

The discussion section has been revised to include a more critical engagement with the literature, comparing findings with previous research and contextualizing them within broader regional trends.
Overgeneralizations have been removed, and the discussion now closely reflects the empirical findings.
A more detailed account of the study’s limitations has been added, including issues of sampling, scale design, and generalizability.
Practical implications and policy recommendations are now discussed in more depth, suggesting ways to address the identified barriers through education, healthcare provider training, and community outreach.

6. Conclusion

Specific conclusions related to each domain (cognitive, affective, behavioral) have been articulated.
Clear, actionable recommendations for policy, health education, and community engagement have been provided.
Future research directions are proposed, including the need for larger, more representative samples and the inclusion of other Middle Eastern countries.

7. References

The reference list has been thoroughly updated to include more recent and directly relevant studies, particularly from 2020 onwards.
Irrelevant or outdated sources have been removed or replaced with more appropriate ones.

8. Language and Formatting

The manuscript has been carefully revised for grammar, phrasing, and clarity.
Repetitive sections have been streamlined to improve readability and coherence throughout the paper.

Once again, I thank you sincerely for your constructive critique, which has greatly contributed to the improvement of the manuscript. I hope the revised version addresses your concerns and meets the standards expected by the journal.
Kind regards

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Competing Interests

i have no any competing interest

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Reviewer Report

19 Views

11 Oct 2024 | for Version 1

Amy Tsui, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA

19 Views Cite this report Responses(1)

Not Approved

Is the work clearly and accurately presented and does it cite the current literature?

No
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

No
If applicable, is the statistical analysis and its interpretation appropriate?

No
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

No

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Reproductive health behaviors

Respond to this report

Responses (1)

Author Response

23 Aug 2025

Hawraa Ghafel , Doctor in Maternal and Neonate Nursing Department, College of Nursing, University of Baghdad, Bab Al-Mua’adham, 10011, Iraq

Dear Reviewer,
Thank you very much for your thoughtful and detailed review of my manuscript. I truly appreciate the time and effort you devoted to providing constructive feedback, which has helped me significantly improve the quality and clarity of the study. Please find below my responses to your comments and the changes made accordingly:

On modern contraceptive prevalence rates (mCPR):
I fully acknowledge your observation regarding the relatively robust mCPR levels in several Middle Eastern countries. In the revised version, I have included data from the UN’s 2022 World Contraceptive Use database and emphasized that while modern contraceptive use exists at moderate to high levels in the selected countries, significant attitudes especially cognitive, affective, and behavioral—still influence non-use or inconsistent use among subgroups of women. This has been clarified in both the introduction and discussion sections to avoid any misleading generalizations.
On the sample and country selection:
I agree with your concern regarding the small, purposive sample. I have now added a detailed justification for the inclusion of Iraq, Lebanon, Jordan, Yemen, Saudi Arabia, and Egypt, highlighting their contextual diversity in terms of contraceptive policies, healthcare systems, and sociocultural norms. I have also clarified the limitations of the convenience sampling approach and its implications for generalizability.
Regarding the sample size, I have specified that the original calculation was based on a 0.5 estimated proportion with a 95% confidence level, but due to feasibility constraints and ethical approvals in clinical settings, a smaller sample was used. I have revised the confidence level discussions in the methodology section accordingly.
On the theoretical framework (cognitive, affective, behavioral):
I have now defined each domain clearly in the methodology section, based on relevant literature from health psychology and behavioral science. I have also added references supporting the rationale for attitudes under these three domains, which align with well-established models such as the Theory of Planned Behavior.
On scale design and analysis:
Based on your helpful feedback, I recognize the limitation of using a 3-point Likert scale. While it was initially chosen for simplicity and clarity among participants with varied educational backgrounds, I have now included this rationale in the methodology, along with a discussion of its potential limitations in the analysis section.
Furthermore, I have provided separate Cronbach’s alpha values for each domain to reflect internal consistency more accurately. Due to sample size constraints, principal components analysis could not be conducted; however, I have noted this as a recommendation for future research with larger datasets.
On discussion and conclusions:
The discussion section has been carefully revised to ensure it reflects only what has been empirically analyzed. Overgeneralizations have been removed, and the conclusions are now more tightly grounded in the study's specific findings.

Once again, I am sincerely grateful for your comments, which have contributed substantially to strengthening the manuscript. Please feel free to share any further thoughts or suggestions.
Kind regards

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Competing Interests

I have no any competing interest

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Understanding of middle east women’s decisions and barriers to use family planning methods

Abstract

Background

Objectives

Methodology

Results

Conclusions

Keywords

Introduction

Methods

Study setting

Study population

Sample size, sampling technique

Data collection and instruments

Data analysis

Ethical considerations

Results

Table 1. Socio-demographic Demographic Characteristics of Women.

Table 2. Evaluation of Affective barrier to avoid use of family planning methods among Women (N=198).

Table 3. Evaluation of Behavioral barrier to avoid use of family planning methods among Women (N = 198).

Table 4. Evaluation of Cognitive barrier to avoid use of Family Planning Methods among Women (N=198).

Discussion

Conclusions

Ethics and consent

CRediT authorship contribution statement

Data availability

Underlying data

Extended data

Acknowledgments

References

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