Utilization of modern contraceptive methods and its determinants among youth in Myanmar: Analysis of Myanmar Demographic and Health Survey (2015-2016)

Ciin Ngaih Lun; Thida Aung; Kyaw Swa Mya

doi:10.1371/journal.pone.0258142

. 2021 Oct 6;16(10):e0258142. doi: 10.1371/journal.pone.0258142

Utilization of modern contraceptive methods and its determinants among youth in Myanmar: Analysis of Myanmar Demographic and Health Survey (2015-2016)

Ciin Ngaih Lun ^1,^‡, Thida Aung ^2,^#, Kyaw Swa Mya ^3,^*,^#

Editor: Janet E Rosenbaum⁴

PMCID: PMC8494330 PMID: 34614023

Abstract

Reproductive health service is crucial for youth to reduce maternal and child mortality. However, many young women face unintended pregnancies and pregnancy-related complications due to insufficient knowledge of contraceptive methods and low contraceptive utilization. This study aims to assess the modern contraceptive prevalence rates among youth and identify factors influencing modern contraceptive utilization among youth. We used Myanmar Demographic and Health Survey (2015–2016) data. This study included 1,423 men and 3,677 women aged 15–24 years from all states and regions of Myanmar. We used multivariable binary logistic regression analysis and reported the results using adjusted Odds Ratios (AOR) with 95% Confidence Intervals (CI). Data analysis was done by STATA software (version 15.1). Ever-married youth used mainly injectable contraception, followed by oral contraceptive pills. Never-married male youth mainly used oral contraceptive pills; however, almost all never-married female youth did not use contraception. The modern contraceptive prevalence rates were 14.9% among total youth, 10% among males, 16.8% among females, 1.5% among never-married males, 44.7% among ever-married males, and 54% among ever-married female youth. The knowledge on modern contraceptive methods favored the utilization. Sexually active youth utilized more contraception than sexually inactive youth. We also found geographical variation and low utilization among rural youth. The desire for more children was also a significant predictor of contraceptive utilization among married youth. The utilization of modern contraception was low among Myanmar youth. Reproductive health program needs to be emphasized on the youth population especially in the area with low utilization to have equitable access to quality reproductive health services. Moreover, the revitalization of Youth Information Corner and youth-friendly reproductive health education programs should be implemented to increase reproductive health knowledge and prevent unsafe sex, unintended pregnancies, and abortions which might help in reducing maternal and child mortality. We warranted conducting mixed method studies to explore the barriers and challenges of contraceptive utilization and male involvement in the choice of contraception among youth.

Introduction

Youth has been defined as the person between 15 and 24 years of age by the United Nations since 1981. It is the critical transitional period, from childhood dependence to adulthood independence, during which physical, psychological, social, and sexual changes occur [1]. Youth is the time when most people start exploring their sexuality and having an intimate relationship [2]. Sustainable development goals (SDGs) Goal 3 under Target 3.7 stated, "By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programs" [3]. Therefore, youth must have the right to get quality sexual and reproductive health services and make decisions free from any violence, discrimination, and coercion [4].

Globally, pregnancy in young people has become a major public health issue for youth health. About 10% to 40% of young females encounter unwanted pregnancies in developing countries [5]. Young women who start their first sexual intercourse at young ages are less likely to use contraceptive methods due to a lack of knowledge and access to contraceptive methods [6, 7]. Getting the proper knowledge of contraception before starting the first sexual activity is essential for youth to prevent wrong decision-making, sexually transmitted infections, and unwanted pregnancy. Some studies have projected that if there were effective contraception usage among youth, it would reduce unintended pregnancies by 59%, unplanned births by 62%, abortion by 57%, miscarriage of unintended pregnancies by 71%. Moreover, nearly 32% of maternal mortality, 90% of abortion-related, and 20% of pregnancy-related morbidity and mortality could be prevented [8, 9]. Therefore, knowledge and utilization of contraception among youth play an essential role in saving women’s lives by reducing unwanted and high-risk pregnancies, unsafe abortion, and maternal mortality and improving the survival rates of newborn children by lengthening the interval between pregnancies [4].

In Myanmar, having sexual activity among youth aged 15–19 years was about 12% among girls and 7% among boys. In youth aged 20–24 years, the practice was about 48% among girls and 43% among boys [10]. The adolescent birth rate is 33 per 1,000 women aged 15–19 years, and the age-specific fertility rate for 20–24 years old is 108 per 1,000 women [11]. The ratios of newborn infant death to age group-specific births were about 6% in 15–19 years age group mothers and 4.6% in the age groups of 20–24 years old mothers [12].

The Ministry of Health and Sports (MOHS), Myanmar, in collaboration with UNFPA and WHO, published the Five-Year Strategic Plan for Young People’s Health (2016–2020). Four targets related to reproductive health were: 1) to reduce adolescent fertility rate from 20 per 1,000 in 2014 to 10 per 1,000 in 2018; 2) to increase the contraceptive prevalence rate among sexually active young people from 38% in 2014 to 52% in 2018; 3) to reduce MMR(Maternal Mortality Rate) among young pregnant mother and 4) to increase the proportion of young people with correct knowledge of Sexual and Reproductive Health and HIV/AIDS [13]. To meet these mandates, Myanmar policymakers and planners need a broad understanding of sexual and reproductive health issues, such as utilizing modern contraceptives among Myanmar youth, their determinants, and how they vary according to sex.

In Myanmar, the Youth Information Corners (YICs) have been established since 2002 by the Health Education Division under the Ministry of Health, supporting UNFPA to promote reproductive health knowledge among youth [14]. YICs began with 17 rural health centers in 2002 and eventually reaching 70 health centers across the country in 2012. YICs act as a library providing literature on reproductive health and other youth-related information, edutainment devices for youth. YICs also aimed to train youth volunteers to become peer educators on reproductive health issues. However, most of the YICs had stopped operating at the time of situation analysis. Hence, the Five-Year Strategic Plan for Young People’s Health recommended an immediate rejuvenation of the YIC program [13].

There are some Myanmar studies regarding contraceptive utilization [15–19]. These studies were conducted among men, reproductive-aged women, and married migrant women and not focused on the youth population. Mon et al. conducted a study among married youth and their husband to assess the contraceptive utilization [20], and Lat et al. also conducted a study among never-married youth regarding premarital sex [21]; however, these studies used a small sample to represent a particular township rather than the whole country. Therefore, we conducted this study to assess the utilization of modern contraception and its determinants among Myanmar youth.

Materials and methods

We used the Myanmar Demographic and Health Survey (MDHS) data, a nationally representative population-based survey conducted during 2015–16. The detailed methodology of this survey was published elsewhere [10]. It was a nationwide cross-sectional study that allowed estimates of key indicators at the national level, urban and rural areas, and all states and regions of Myanmar. The sample was a stratified two-stage cluster sample of households that included 442 clusters (123 from urban areas and 319 from rural areas): 30 households from each cluster to get 13,260 households using equal probability systematic sampling. All women aged 15–49 years from selected households and all men aged 15–49 years from a subsample consisting of one household in every second household selected for the female survey were eligible. A total of 12,885 women and 4,737 men were interviewed in the survey. From those, we included 1,423 men and 3,677 women age 15–24 years in this study.

Dependent variable

We used the utilization of modern contraceptive methods among Myanmar youth as a dependent variable. The modern contraceptive methods used in MDHS’s annual report are as follow– 1) male sterilization, 2) female sterilization, 3) intrauterine device (IUD), 4) contraceptive implant, 5) injectable contraception, 6) oral contraceptive pill, 7) male condom, 8) female condom, 9) emergency contraception, 10) lactational amenorrhea method and 11) others (cervical cap and sponge) [10]. If the respondent or sexual partner currently used any type of modern contraception at the time of the survey, he or she was categorized as used modern contraceptives coded as "yes" and, if not, categorized as did not use modern contraceptives coded as "no".

Independent variables

We used the number of modern contraceptive methods known by youth as an independent variable. We gave score-1 for every method known by youth. Hence, the possible score ranged from 0 to 11, and we treated this variable as a continuous variable. Moreover, we also used the individual and household characteristics of youth as independent variables. The individual characteristics were age, sex, marital status, education, employment, previous exposure to family planning messages, sexual activity, and desire for more children. We categorized the age into 15–19 years and 20–24 years and sex into male and female. The marital status was categorized into never-married and ever-married, which included currently married, widowed, separated. The education level was categorized into no education, primary, secondary and above.

The employment variable was recoded as "yes" if the respondent had an earning job within 12 months before the survey or "no" otherwise. The exposure to family planning messages variable was recoded as "yes" if he or she heard about family planning messages from any one of TV, radio, newspaper, internet, billboard, health care provider within 12 months before the survey. If they had not heard any family planning messages, they were recoded as "no". Sexually activity was recoded as "active" if the respondent had sexual activity within four weeks before the survey, and if not, it was recoded as "not active". The information of desire for more children was available only for ever-married youth. It was categorized into "yes" if the youth desired to get more children and "no" if they did not want any more children or fecund or never had sex.

The household characteristics were the residence (categorized into urban and rural residence), geographical zone (categorized into the hilly, coastal, delta, and central plain), and wealth index (categorized into rich, middle, and poor).

Statistical analysis

Data were analyzed using STATA software (version 15.1). We used the survey data analysis command (svy) to adjust the cluster survey design and non-response rates for each analysis. All estimates were weighted to represent the whole population in the nation. We described the modern contraceptives prevalence rate (mCPR) with 95% error bars for total youth, ever-married youth, never-married youth, male youth, and female youth. Frequency distribution tables reported the background characteristics of the sample. We used the Chi-square test of independence to assess the relationship between independent variables and dependent variable. We checked the multicollinearity; however, we did not find any highly correlated independent variables.

We used the multivariable binary logistic regression analysis to assess the factors influencing the utilization of modern contraceptive methods. We analyzed the data separately for never-married and ever-married youth for each sex to distinguish the marital status’s effect on contraceptive utilization. Since the utilization was extremely low among never-married females (only one female youth utilized contraceptives), it was impossible to analyze for this group. Hence, we did not report for never-married females in the Results section. Moreover, we assessed the gender’s effect on utilization by analyzing separately for male youth and female youth without considering the marital status and the marital status’s effect on utilization by analyzing separately for never-married youth and ever-married youth without considering the gender difference. We reported the results using adjusted odds ratios (AOR) with 95% confidence intervals. P-value <0.05 was set as a statistical significance.

Ethical consideration

The MDHS protocol was approved by the Ethics Review Committee on Medical Research, including Human Subjects in the Department of Medical Research, the Ministry of Health and Sports, and the ICF Institutional Review Board, respectively. A verbal informed consent was taken from each participant before interview. MDHS data are fully anonymized so that all individual identifiers could not be accessible by data users. We obtained the Ethical approval for this study from the Institutional Review Board of the University of Public Health (UPH-IRB (2020/MPH/2)).

Results

We reported the background characteristics of youth in Table 1. The mean age of married youth was older than that of unmarried youth for both sexes (22 vs. 19 years for males and 21 vs. 19 years for females). The number of youth who passed secondary and higher education among unmarried was more than that of married youth for both sexes (72.4% vs. 53.4% for male and 72.5% vs. 49.3% for female). Almost all married male youth were employed; however, about half of married female youth were employed. Male youth had higher exposure to family planning messages than female youth for both unmarried and married youth.

Table 1. The individual and household characteristics of youth in Myanmar.

Variables	Male youth (N = 1,423)		Female youth (N = 3,677)
Variables	Never-married (n = 1,143)	Ever-married (n = 280)	Never-married (n = 2,533)	Ever-married (n = 1,144)
Individual characteristics
Age
15–19 years	693 (60.6)	39 (13.9)	1564 (61.8)	246 (21.5)
20–24 years	450 (39.4)	241 (86.1)	969 (38.2)	898 (78.5)
Mean ± SD	19 ± 2.7	22 ± 1.9	19 ± 2.8	21 ± 2.2
Education
No education	81 (7.1)	28 (9.9)	122 (4.8)	142 (12.4)
Primary	235 (20.5)	103 (36.7)	575 (22.7)	438 (38.3)
Secondary and higher	827 (72.4)	149 (53.4)	1,836 (72.5)	564 (49.3)
Employment
No	290 (25.4)	7 (2.4)	989 (39.1)	515 (45.0)
Yes	853 (74.6)	273 (97.7)	1,543 (60.9)	629 (55.0)
Exposure to family planning messages
No	547 (47.9)	132 (47.2)	1,368 (54.0)	668 (58.4)
Yes	596 (52.1)	148 (52.8)	1,165 (46.0)	476 (41.6)
Sexually active
No	1,123 (98.2)	40 (14.4)	2,533 (100.0)	282 (24.7)
Yes	20 (1.8)	240 (85.6)	0 (0.0)	862 (75.3)
Desire for more children ^†
Yes		202 (72.1)		701 (61.3)
No		78 (27.9)		443 (38.7)
Household characteristics
Residence
Urban	369 (32.3)	73 (26.0)	845 (33.4)	276 (24.1)
Rural	774 (67.7)	207 (74.0)	1,688 (66.6)	868 (75.9)
Geographical zone
Hilly	185 (16.2)	70 (24.8)	450 (17.8)	247 (21.6)
Coastal	155 (13.6)	28 (10.0)	324 (12.8)	168 (14.7)
Delta	421 (36.8)	104 (37.4)	967 (38.2)	412 (36.0)
Central plain	382 (33.4)	78 (27.8)	792 (31.2)	317 (27.7)
Wealth index
Poor	392 (34.3)	114 (40.9)	788 (31.1)	531 (46.4)
Middle	255 (22.4)	65 (23.2)	553 (21.9)	224 (19.5)
Rich	496 (43.4)	101 (35.9)	1192 (47.1)	389 (34.1)

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The results were presented by n (%). SD: Standard Deviation,

^†This information was only available for ever-married youth in MDHS.

The data of responding "not sure, never had sex and missing values" were added to the "No desire for more children" category group.

None of the never-married female youth was sexually active, and only 1.8% of never-married male youth were sexually active. In comparison, 85% of males and 75% of females among married youth were sexually active. Most of the youth were from the rural area, i.e., about two-third of never-married youth and three-fourths of ever-married youth. Delta zone had the highest number of youth, and the coastal zone had the lowest number of youth for both sexes and all marital statuses. Almost half of the never-married youth were from rich households (43% for male and 47% for female); however, nearly half of the ever-married youth were from poor households (41% for male and 46% for female).

We described the modern contraceptive methods known by youth in Fig 1. Among never-married male youth, the male condom was the most known method (82%), followed by oral contraceptive pill (72%) and injectable contraception (71%). Among never-married female youth, injectable contraception (88%) was the most known method, followed by oral contraceptive pills (86%) and female sterilization (73%). See detail in Fig 1a.

Among ever-married male youth, injectable contraception was the most known method (89%), followed by oral contraceptive pills (88%) and male condoms (83%). Among ever-married female youth, injectable contraception (96%) was the most known method, followed by oral contraceptive pills (94%) and female sterilization (80%). See detail in Fig 1b.

We reported the total numbers of modern contraceptive methods known by youth in Table 2. Among never-married youth, most male youth (17%) knew four methods, while most female youth (17%) knew six modern contraception methods. Among ever-married youth, male youth (19%) mostly knew five methods while female youth (16%) mostly knew six modern contraception methods. Youth who did not know any contraceptive method were 10% among never-married male youth, 7% among never-married female youth, 6% among ever-married male youth, and 3% among ever-married female youth.

Table 2. Number of modern contraceptive methods known by youth in Myanmar.

Number of modern contraceptive methods known by the youth	Male youth (N = 1,423)		Female youth (N = 3,677)
Number of modern contraceptive methods known by the youth	Never-married (n = 1,143)	Ever-married (n = 280)	Never-married (n = 2,533)	Ever-married (n = 1,144)
0	110 (9.6)	16 (5.6)	188 (7.4)	39 (3.4)
1	97 (8.5)	11 (4.0)	85 (3.4)	20 (1.8)
2	107 (9.4)	17 (6.3)	178 (7.0)	86 (7.5)
3	166 (14.5)	26 (9.2)	277 (11.0)	80 (7.0)
4	194 (17.0)	44 (15.8)	373 (14.7)	107 (9.4)
5	164 (14.3)	53 (18.9)	407 (16.1)	130 (11.3)
6	111 (9.7)	42 (15.0)	422 (16.7)	183 (16.0)
7	86 (7.5)	28 (9.9)	288 (11.4)	182 (15.9)
8	62 (5.4)	23 (8.1)	177 (7.0)	153 (13.4)
9	35 (3.0)	13 (4.8)	86 (3.4)	112 (9.8)
10	11 (1.0)	7 (2.5)	52 (2.0)	48 (4.2)
11	0 (0)	0 (0)	0 (0)	4 (0.3)

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The results were presented by n (%). Six missing values were added to no known contraceptive method group.

We described the types of modern contraceptive methods used by youth in Table 3. Among never-married male youth, the oral contraceptive pill was mostly used (1.1%), followed by injectable contraception (0.2%) and others (cervical cap and sponge) (0.2%). Among ever-married male youth, injectable contraception was mostly used (25%), followed by oral contraceptive pill (18%), intrauterine device (0.6%), and female sterilization (0.6%). Almost all of the never-married female youth (99.97%) did not use any method of contraception, and only 0.03% used oral contraceptive pills. Among ever-married female youth, injectable contraception was mostly used (33%), followed by oral contraceptive pill (19%), intrauterine devices (0.9%), contraceptive implants (0.6%), female sterilization (0.3%), male condom (0.2%) and others (0.08%).

Table 3. Types of modern contraceptive methods used by youth in Myanmar.

Contraceptive methods used by Myanmar youth	Male (N = 1,423)		Female (N = 3,677)
Contraceptive methods used by Myanmar youth	Never-married (n = 1,143)	Ever-married (n = 280)	Never-married (n = 2,533)	Ever-married (n = 1,144)
No method	1,121 (98.0)	155 (55.3)	2,532 (99.97)	523 (45.7)
Injectable contraception	2 (0.2)	70 (25.2)	0 (0.0)	378 (33.1)
Oral contraceptive pill	13 (1.1)	51 (18.2)	1 (0.03)	216 (18.9)
Intrauterine devices	0 (0.0)	2 (0.6)	0 (0.0)	10 (0.9)
Contraceptive implants	0 (0.0)	0 (0.0)	0 (0.0)	6 (0.6)
Female sterilization	0 (0.0)	2 (0.6)	0 (0.0)	4 (0.3)
Male condom	0 (0.0)	0 (0.0)	0 (0.0)	2 (0.2)
Others	2 (0.2)	0 (0.0)	0 (0.0)	1 (0.08)

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Multiple responses, Presented by n (%).

Fig 2 shows the mCPR of Myanmar youth. The mCPR was 14.9% [95%CI: 13.6, 16.3] among all youth, 10% [95%CI: 8.4, 11.9] among male youth, and 16.8% [95%CI: 15.3, 18.5] among female youth. It was 52.2% [95%CI: 48.9, 55.4] among all ever-married youth, 44.7% [95%CI: 37.6, 52.0] among ever-married male youth and 54% [95%CI: 50.6, 57.4] among ever-married female youth. It was 0.5% [95%CI: 0.3, 0.9] among all never-married youth, 1.5% [95%CI: 0.8, 2.7] among never-married male youth; however, only one never-married female youth utilized modern contraception.

We performed the test for trend across the ordered group to assess whether there is a trend in mCPR as increased in the number of modern methods known among total youth (n = 5100). We found a significant increasing trend (p<0.001), i.e., as the number of methods known increased, the mCPR also increased. See detailed in Fig 3.

We assessed the relationship between modern contraceptive methods utilization and background characteristics and reported in Table 4. Since almost all never-married female youth did not utilize modern contraception, we did not report for never-married female youth. Older youth (20-24years) had higher modern contraceptive utilization than younger youth (15-19years); however, it was significant only for never-married male youth (3.2% vs. 0.4%). Regarding educational status, we found the increased utilization trend as the education status increased only among ever-married female youth (40.4% in no education, 51.1% in primary education, and 54.9% in secondary and higher education). Sexually active youth utilized contraception significantly more than sexually not active youth in all groups.

Table 4. The association between modern contraceptive methods utilization by background characteristics among youth in Myanmar (Bivariate analysis).

Variables	Male youth(n = 1,423)		Female youth(n = 3,677)
	Never-married (n = 1,143)	Ever-married (n = 280)	Ever-married (n = 1,144)
	mCPR% [95%CI]	mCPR% [95%CI]	mCPR%[95%CI]
Individual characteristics
Age	p = 0.001	p = 0.135	p = 0.142
15–19 years	0.4 [0.1, 1.2]	32.0 [17.7, 50.8]	49.2 [42.0, 56.4]
20–24 years	3.2 [1.7, 6.0]	46.7 [39.2, 54.4]	55.3 [51.4, 59.2]
Education	p = 0.541	p = 0.090	p = 0.003
No education	1.0 [0.1, 7.2]	21.7 [7.0, 50.6]	40.4 [30.2, 51.5]
Primary	0.7 [0.1, 4.4]	41.8 [30.2, 54.4]	51.1 [45.2, 56.8]
Secondary and higher	1.8 [0.9, 3.3]	51.0 [41.8, 60.1]	59.9 [54.9, 64.7]
Employment	p = 0.798	p = 0.311	p = 0.774
No	1.3 [0.5, 3.8]	64.2 [26.7, 89.8]	53.4 [48.4, 58.4]
Yes	1.6 [0.8, 3.1]	44.2 [37.0, 51.7]	54.5 [49.6, 59.3]
Exposure to family planning messages	p = 0.357	p = 0.128	p = 0.097
No	1.1 [0.4, 3.0]	38.5 [28.8, 49.2]	51.3 [46.8, 55.8]
Yes	1.9 [0.9, 3.8]	50.3 [39.8, 60.7]	57.8 [52.0, 63.4]
Sexually active	p<0.001	p = 0.001	p<0.001
No	0.7 [0.3, 1.5]	15.9 [7.6, 30.2]	21.7 [16.6, 27.7]
Yes	46.2 [21.3, 73.2]	49.5 [41.7, 57.4]	64.6 [60.6, 68.4]
Desire for more children^†		p = 0.393	p = 0.205
Yes		46.8 [38.8, 55.0]	52.2 [47.4, 57.0]
No		39.3 [25.7, 54.7]	56.9 [51.7, 61.9]
Household characteristics
Residence	p = 0.017	p = 0.960	p = 0.014
Urban	3.0 [1.4, 6.3]	44.4 [30.5, 59.2]	61.3 [54.8, 67.4]
Rural	0.8 [0.3, 1.9]	44.8 [36.7, 53.2]	51.7 [47.7, 55.7]
Geographical zone	p = 0.603	p = 0.004	p<0.001
Hilly	1.5 [0.3, 6.9]	25.1 [13.7, 41.4]	34.5 [28.1, 41.4]
Coastal	0.8 [0.2, 3.5]	48.1 [33.1, 63.4]	39.5 [32.5, 46.9]
Delta	2.2 [0.9, 5.0]	58.1 [46.1, 69.3]	71.9 [66.0, 77.2]
Central plain	1.1 [0.4, 2.8]	42.9 [30.7, 56.2]	53.7 [46.8, 60.4]
Wealth index	p = 0.042	p = 0.085	p = 0.923
Poor	0.3 [0.0, 1.3]	35.8 [25.2, 47.8]	53.3 [48.3, 58.3]
Middle	1.3 [0.4, 4.5]	58.0 [41.5, 72.8]	55.0 [47.2, 62.5]
Rich	2.5 [1.2, 5.0]	46.3 [35.1, 57.9]	54.4 [48.5, 60.2]

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The data of responding "not sure, never had sex and missing values" were added to the "No desire for more children" category group.

^†This information was only available for ever-married youth in MDHS.

P values were calculated using the Chi-square test of independence.

Youth from urban households utilized more contraception than rural households; however, we did not find this urban-rural difference among ever-married male youth. We found a significant regional variation in utilization of modern conception among ever-married male and female youth. The utilization was highest among youth from the delta zone and lowest among youth from the hilly zone. The household wealth status also influenced the modern contraceptive utilization among never-married youth only. We found the highest utilization among youth from the rich households and lowest among youth from poor households (2.5% vs. 0.3%).

We used multivariable binary logistic regression to assess the determinants of modern contraceptive utilization among never-married male youth, ever-married male youth, and ever-married female youth, adjusting the covariates (Table 5). Among never-married male youth, sexual activity and the number of known modern contraceptive methods were significant predictors of utilizing modern contraception. Sexually active youth utilized modern contraception 78 times more than those who were not sexually active. As youth who knew one more modern contraception, the odds of modern contraceptive utilization was 38% increased.

Table 5. Multivariable binary logistic regression analysis of modern contraceptive methods utilization among never-married male, ever-married male and ever-married female youth in Myanmar.

Variables	Never-married male (n = 1,143)	Ever-married male (n = 280)	Ever-married female (n = 1,144)
Variables	AOR [95%CI]	AOR [95%CI]	AOR [95%CI]
Individual characteristics
Age
15–19 years
20–24 years	1.00	1.00	1.00
Education	1.95 [0.56, 6.72]	1.49 [0.64, 3.46]	1.12 [0.81, 1.54]
No education	1.00	1.00	1.00
Primary	0.23 [0.02, 2.96]	1.49 [0.41, 5.37]	1.04 [0.65, 1.67]
Secondary and higher	0.13 [0.01, 1.51]	1.50 [0.40, 5.63]	1.27 [0.76, 2.11]
Employment
No Yes	1.00	1.00	1.00
No Yes	0.62 [0.17, 2.30]	0.80 [0.17, 3.67]	1.00 [0.77, 1.31]
Exposure to family planning messages
No	1.00	1.00	1.00
Yes	1.76 [0.39, 8.00]	1.10 [0.60, 2.01]	0.79 [0.58, 1.07]
Sexually active
No	1.00	1.00	1.00
Yes	78.12^***[17.38, 351.07]	3.47^** [1.57, 7.69]	6.96^*** [5.01, 9.69]
Desire for more children^†
Yes		1.00	1.00
No		1.16 [0.61, 2.19]	1.49^** [1.12, 2.00]
Number of known modern contraceptive methods	1.38^* [1.04, 1.83]	1.12 [0.98, 1.29]	1.18^*** [1.10, 1.25]
Household characteristics
Residence
Urban	1.00	1.00	1.00
Rural	0.39 [0.10, 1.53]	0.88 [0.44, 1.72]	0.69^* [0.48, 0.98]
Geographical zone
Delta	1.00	1.00	1.00
Hilly	1.52 [0.23, 9.84]	0.30^** [0.14, 0.63]	0.29^*** [0.20, 0.43]
Coastal	1.44 [0.19, 10.77]	0.68 [0.29, 1.58]	0.37^*** [0.24, 0.56]
Central plain	2.75 [0.51, 14.89]	0.75 [0.37, 1.55]	0.56^** [0.38, 0.83]
Wealth index
Poor	1.00	1.00	1.00
Middle	0.98 [0.16, 5.80]	1.47 [0.71, 3.04]	0.79 [0.55, 1.13]
Rich	0.67 [0.11, 3.99]	0.98 [0.46, 2.11]	0.74 [0.51, 1.08]

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***p<0.001,

**p<0.01,

*p<0.05,

AOR: adjusted odds ratio, CI: Confidence Interval.

^†This information was only available for ever-married youth in MDHS.

The results of never-married female youth were not described due to very little contraceptive utilization among them.

Among ever-married male youth, sexual activity and geographical zone were significant predictors of modern contraceptive utilization. Sexually active youth were 3.5 times more likely to use modern contraception than those who were not sexually active. Youth from the hilly zone had 70% fewer odds of using modern contraception than those from the delta zone.

Among ever-married female youth, sexual activity, desire for more children, number of known modern contraceptive methods, and geographical zone were significant predictors of modern contraceptive utilization. Sexually active youth were seven times more likely to use modern contraception than sexually not active youth. Youth who did not want more children were 49% more likely to use modern contraception than youth who want more children. Increased in knowing one more modern contraceptive method had 18% higher odds of modern contraceptive utilization among ever-married female youth. Youth living in rural areas were 31% less likely to utilize modern contraception than urban areas. Regional differences of ever-married female youth were significantly associated with differences in modern contraceptive utilization. Youth from the hilly zone, coastal zone, and central plain zone were less likely to use modern contraception than youth from the delta zone by 71%, 63%, and 44%.

We reported the multivariable binary logistic regression analysis of modern contraceptive methods utilization among male, female, ever-married, and never-married youth in Table 6, adjusting the covariates. Among total male youth, age, sexual activity, number of known modern contraceptive methods, and geographical zone were significant predictors of modern contraception. Older male youth had two times more likely to use modern contraception than younger male youth. The utilization of sexually active male youth was 41 times more than sexually not active male youth. Increased knowledge of one more modern contraception method had an 18% higher chance of modern contraceptive utilization among male youth. Youth from the hilly zone had less odds of modern contraceptive utilization than youth from the delta zone by 59%.

Table 6. Multivariable binary logistic regression analysis of modern contraceptive methods utilization among male youth, female youth, ever-married youth, and never-married youth in Myanmar.

Variables	Male youth (n = 1,423)	Female youth (n = 3,677)	Ever-married youth (n = 1,424)	Never-married youth (n = 3,676)
Variables	AOR [95%CI]	AOR [95%CI]	AOR [95%CI]	AOR [95%CI]
Individual characteristics
Age
15–19 years	1.00	1.00	1.00	1.00
20–24 years	2.21^* [1.16, 4.22]	1.79^*** [1.34, 2.39]	1.12 [0.84, 1.51]	2.33 [0.70, 7.74]
Education
No education	1.00	1.00	1.00	1.00
Primary	1.04 [0.32, 3.32]	0.95 [0.58, 1.56]	1.06 [0.69, 1.65]	0.33 [0.03, 3.63]
Secondary and higher	0.90 [0.27, 2.97]	0.82 [0.48, 1.37]	1.21 [0.76, 1.93]	0.16 [0.01, 1.74]
Employment
No	1.00	1.00	1.00	1.00
Yes	1.10 [0.45, 2.67]	0.84 [0.65, 1.09]	0.90 [0.71, 1.15]	0.61 [0.18, 2.04]
Exposure to family planning messages
No	1.00	1.00	1.00	1.00
Yes	1.06 [0.62, 1.84]	0.79 [0.59, 1.05]	0.84 [0.64, 1.09]	1.78 [0.45, 7.02]
Sexually active
No	1.00	1.00	1.00	1.00
Yes	41.06^*** [22.87, 73.71]	54.07^*** [39.89, 73.30]	6.14^*** [4.53, 8.31]	265.34^***[61.69, 1141.37]
Desire for more children ^†
Yes			1.00
No			1.45^** [1.11, 1.88]
Number of known modern contraceptive methods	1.18^** [1.05, 1.34]	1.23^*** [1.16, 1.31]	1.18^*** [1.11, 1.25]	1.23 [0.94, 1.62]
Household characteristics
Residence
Urban	1.00	1.00	1.00	1.00
Rural	0.72 [0.40, 1.30]	0.65^** [0.47, 0.91]	0.73^* [0.53, 0.99]	0.39 [0.10, 1.46]
Geographical zone
Delta	1.00	1.00	1.00	1.00
Hilly	0.41^** [0.21, 0.81]	0.37^*** [0.26, 0.53]	0.30^*** [0.21, 0.42]	1.25 [0.21, 7.33]
Coastal	0.86 [0.42, 1.78]	0.42^*** [0.28, 0.62]	0.43^*** [0.29, 0.62]	2.36 [0.38, 14.55]
Central plain	1.02 [0.54, 1.93]	0.64^* [0.45, 0.92]	0.61^** [0.43, 0.86]	2.54 [0.51, 12.64]
Wealth index
Poor	1.00	1.00	1.00	1.00
Middle	1.45 [0.76, 2.78]	0.78 [0.54, 1.11]	0.92 [0.67, 1.27]	0.78 [0.14, 4.29]
Rich	0.95 [0.48, 1.89]	0.68^* [0.47, 0.97]	0.79 [0.57, 1.10]	0.59 [0.11, 3.23]

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*** p<0.001,

** p<0.01,

* p<0.05,

AOR: adjusted odds ratio, CI: Confidence Interval.

^†This information was only available for ever-married youth in MDHS and analyzed among ever-married youth in logistic regression.

Among total female youth, age, sexual activity, number of known modern contraceptive methods, residence, geographical zone, and wealth status were significant predictors of modern contraception. Older female youth were 1.79 times more likely to use modern contraception than younger female youth. Female youth who were sexually active utilized 54 times more than those who were not sexually active. Increased in knowing one more method increased 23% higher odds of modern contraceptive utilization. Female youth from rural areas were 35% less likely to use modern contraception than urban areas. Youth from the hilly zone, coastal zone, and central plain zone had less odds of modern contraceptive utilization than youth from the delta zone by 63%, 58%, and 36%. Female youth from rich households were 32% less likely to use modern contraception than poor households.

Among ever-married youth, sexual activity, desire for more children, the number of known modern contraceptive methods, residence, and geographical zone were significant predictors of modern contraceptive utilization. Sexually active youth were six times more likely to use modern contraceptives than those who were not sexually active. Youth who did not want more children used modern contraception 1.5 times more than those who want more children. One more known modern contraceptive method increased modern contraceptive utilization by 18%. Youth living in rural areas were 23% fewer odds to use modern contraception than urban areas. Youth from the hilly zone, coastal zone, and central plain zone had less odds of modern contraceptive utilization than youth from the delta zone by 70%, 57%, and 39%.

Among never-married youth, sexual activity was the only predictor of modern contraceptive utilization. Sexually active youth were 265 times more likely to use modern contraception than those who were not sexually active.

Discussion

The mCPR was low among Myanmar youth: 15% among total youth, 10% among males, and 16.8% among female youth. Nearly similar findings were found in Mali (15.3% in 2012) [22], Philippines (10% in 2017) [23], and Nepal (14.6% in 2016) [24]. The reason for low modern contraceptive utilization might be due to insufficient knowledge of reproductive health, difficulties in accessing quality reproductive health services due to social, financial, or geographical inequalities [13, 25]. Although overall utilization was low, the mCPR among ever-married youth was acceptable, i.e., 52.2% among all ever-married youth, 44.7% for ever-married male youth, and 54% for ever-married female youth. This finding was almost the same with the overall mCPR of reproductive Myanmar women 15–49 years old (51%) [10] and mCPR of sexually active young women from South Africa (52.2%) [26]. It was also higher than Ethiopia married young women (35.6%) [27]. The mCPR of ever-married youth and female youth reached the target stated in Myanmar’s Five-Year Strategic Plan for Young People’s Health (2016–2020) to increase CPR among sexually active young people from 38% in 2014 to 52% in 2018 [13].

Interestingly, almost all never-married female youth did not use contraception, and they reported as sexually inactive. Myanmar culture and traditional norms seem to play an important role in preventing premarital sex among never-married youth. This fact might be a possible explanation for very low utilization among this group. Another possible reason was that some unmarried youth might be reluctant to consult with health care providers regarding contraceptive services due to promiscuity issues. Hence, youth-friendly health services would be needed to provide effective reproductive health services primarily to never-married youth [21].

The most commonly used modern contraceptive method was injectable contraception followed by oral contraceptive pills among ever-married youth. In contrast, oral contraceptive pills were mostly used method among never-married youth. This finding was similar to modern contraceptive methods used mainly by Ethiopian youth [28], Nepal youth [29], and study over 21 papers of low-and-middle-income countries [30]. These methods were used mainly by youth due to being easily accessible, available, affordable in almost all private and public clinics, and easy to use. Our study found that utilizing long-term contraceptive methods such as implants and intrauterine devices was very low among youth in Myanmar. Hence, accessibility to long-term contraceptive methods should be promoted free of charge at nearby township health centers for ever-married youth with no desire for more children [31]. All reported contraceptive methods by male youth were female contraceptive methods. Moreover, only two married female youth reported condoms as a modern contraceptive method. This finding pointed out that female takes the primary responsibility for contraception, especially for married youth.

A few youths never heard of contraceptives. Among 11 methods of modern contraception, youth mostly knew 4 to 6 methods. This finding is almost the same as the DHS analysis of men from 18 countries in Asia, Africa, the Caribbean, and Latin America. In this study, most knew 4.5 to 8.8 contraceptive methods, including traditional methods [32]. The male condom was a mostly known method, followed by oral contraceptive pill (OC pill) and injectable contraception among never-married male youth. For ever-married youth, injectable contraception was mostly known, followed by OC pill and male condoms. For all female youth, injectable contraception was mostly known, followed by oral contraceptive pills and female sterilization methods. Being easily accessible and increased health education on how to use those methods are supposed to be the reasons for mostly being known among Myanmar youth [33]. Similarly, the same methods with different orders can be found in the DHS study of Ethiopia youth. Oral contraceptive pills were a mostly known method, followed by injectable contraception and male condoms [28].

We found that the older youth had significantly higher utilization than the younger age group among total male youth and female youth. This finding was consistent with the Ethiopian studies [27, 28], Ghana study [34], and Bangladesh study [35]. However, we did not find this age effect when we analyzed it based on marital status. This fact pointed out that the youth from the 20–24 years age group were more likely to be married, and these married youth utilized more contraception than unmarried youth. Moreover, older youth are more knowledgeable, employed, and affordable for contraception than younger youth, which might also be a possible reason for higher utilization. Our study did not find a significant association between education and modern contraceptive utilization. The same finding can be seen in the Myanmar study of men [15], even though many other studies had pointed out that youth with higher education had higher utilization of modern contraception [22, 27, 34].

Our study could not provide a significant association between employment status and utilization of modern contraception. This finding was consistent with the Afghanistan study [36]. This finding might be because the reproductive health program had reached out to all youth regardless of the education status and employment status through media or peer education. Youth who had previous exposure to family planning messages from TV, radio, newspaper, internet, billboard, or health care providers did not significantly influence the utilization of modern contraception. This finding was the same with the Myanmar study of men [15] and Afghanistan study [36]. It might be due to getting the family planning information from other sources such as friends, hearsays, or relatives [31, 37]. It is important not to get the wrong information from unreliable sources. Revitalization Youth Information Corner, promoting reproductive health literacy in the community, and a life-skill curriculum at school would increase the reproductive health knowledge of Myanmar youth, ensuring safer sex among youth in Myanmar [13, 21].

Sexual activity significantly influenced the utilization of modern contraception. The utilization among sexually active youth was significantly higher than that of not sexually active youth, and this finding was consistent with a study in Burkina Faso and Mali [22]. Ever-married youth who did not have a desire for more children significantly utilized more modern contraception than those who wanted more children, and the same finding can be seen in Nepal study [29], Ethiopia study [27], Senegal study [38], and Myanmar study [16].

We found the dose-response relationship between knowledge of known methods and utilization of modern contraception. As increased in the number of known modern contraceptive methods, modern contraceptive utilization also increased. The same finding can be seen in the Senegal study [38], Ethiopia study [39], and Nigeria study [40]. It might be due to youth with high knowledge of contraception having a better choice of modern contraception and more likely to have a positive attitude towards using modern contraception [37].

Youth from the rural areas had significantly lower utilization of modern contraception than youth from urban areas among ever-married youth, female youth, and ever-married female youth. This finding was consistent with the Bangladesh study [35] and West Africa study [22]. However, the residence was not a significant predictor for male youth and never-married youth. The same finding can be seen in the Myanmar men study [15] and the study conducted among men from Asia, Africa, the Caribbean, and Latin America [32]. The difference in accessibility and affordability between urban and rural areas might explain the low utilization of modern contraception among youth from rural areas.

Youth from the hilly, coastal, and central plain zones had significantly lower utilization of modern contraception than youth from the delta zone. This finding was consistent with the Myanmar study [15]. Delta zone includes Yangon, Ayeyarwady, and Bago regions which are the most developed regions in Myanmar. Hence, better accessibility, availability, and affordability of contraception in the delta zone than in other zones might be a possible explanation of regional variation in contraceptive utilization. Current implementing reproductive health programs and services should be equally accessible without geographic variation.

Household wealth status influenced the utilization of contraception only among female youth. Youth from rich households utilized modern contraception less than those from poor households, and it was not consistent with the Ethiopian study [27], Afghanistan study [36], and West Africa study [22]. However, this effect was diminished as we analyzed separately for married and unmarried youth. In Myanmar, both government and non-governmental organizations’ reproductive health clinics provide reproductive health services free of charge or low costs. Hence, wealth status could not be a barrier to modern contraceptive utilization among Myanmar youth.

Strengths and limitations of the study

We used nationally representative data from MDHS (2015–2016), and all analyses were weighted to get national estimates. Therefore, the generalizability of the findings from this study is high. The findings from this study pointed out the country’s contraceptive prevalence rate among youth and factors influencing those conditions, which might help promote youth’s family planning health services by pointing out the area to emphasize.

Although all interviews had been conducted by enumerator-respondent match in terms of gender at a place where privacy was ensured, some cultural barriers might be possible for underestimating contraceptive utilization among never-married youth. The causality cannot be applied because of being data from a cross-sectional survey. Some predictors supported by literature could not be included in this study due to data limitations. Hence, we could not provide evidence of bad outcomes due to not using modern contraception and the success stories of using modern contraception. We could not also assess whether youth who did not use modern contraception leave the school earlier than they would have, get unplanned pregnancy and sexually transmitted infection due to unsafe sex. Although we found female takes the primary responsibility for contraception, our study could not provide the evidence of male participation in the choice of modern contraception. Moreover, we used the data from MDHS (2015–2016); the modern contraceptive prevalence rates and the number of modern contraceptive methods known by youth might be changed during these years. However, the determinants of modern contraceptive utilization might be the same and applicable for program implementation.

Conclusion

The utilization of modern contraception of Myanmar youth was low. The knowledge on modern contraceptive methods favored the utilization. Some youth did not know any modern contraception methods, which was an alarm sign to program implementers to promote reproductive health education effectively among the youth population. The reproductive health program should emphasize the adolescents and never-married youth population, especially in areas with low utilization, such as from the hilly and rural areas, to have equitable access to quality reproductive health services and health literacy. Further studies using the mixed method approach should be conducted to explore the barriers and challenges of contraceptive utilization and male involvement in the choice of contraception among youth. Moreover, revitalization of Youth Information Corner (YIC) and youth-friendly reproductive health services are needed to increase reproductive health knowledge and utilization to prevent unsafe sex, unintended pregnancies, and abortions which might help in reducing maternal and child mortality.

Acknowledgments

We want to thank the DHS Program (ICF) for permitting MDHS data access for this study. We also want to express our sincere gratitude to the Institutional Review Board, University of Public Health, Yangon, for giving ethical clearance to conduct this study.

Data Availability

The Myanmar Demographic and Health Survey data can be downloaded from this URL - https://dhsprogram.com/data/available-datasets.cfm.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0258142.r001

Decision Letter 0

Janet E Rosenbaum

8 Jun 2021

PONE-D-21-13352

Utilization of modern contraceptive methods and its determinants among youth in Myanmar: Further analysis of Myanmar Demographic and Health Survey (2015-2016)

PLOS ONE

Dear Dr. Mya,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Given the situation in Myanmar, I want to give you as much flexibility as possible without limitations or deadlines, but I want to suggest the most important changes that will help improve this paper so that we can publish it. See below for how to request more time.

Required changes:

1. Marital status is clearly such a large determinant of contraceptive use that it makes it hard to see any other effects, and the odds ratios are enormous and the confidence intervals are wide. Please stratify the analysis into married and unmarried to avoid these enormous odds ratios and wide intervals. That is, married females, unmarried females, married males, unmarried males.

2. Studies of contraceptive use generally use a health behavior model to guide studies and later to guide interventions. Examples of health behavior models used to study contraception include social cognitive theory, health belief model, theory of planned behavior, and protection motivation theory. For example, this paper (available on researchgate without a paywall) uses the health behavior model.

Mon MM, Liabsuetrakul T. Predictors of contraceptive use among married youths and their husbands in a rural area of Myanmar. Asia Pac J Public Health. 2012 Jan;24(1):151-60. doi: 10.1177/1010539510381918. Epub 2010 Sep 9. PMID: 20829275. Choose a health behavior model and use it to guide the study and choose important variables. Some important variables could be self-efficacy to use a method, perceived risk of pregnancy, not wanting pregnancy now, etc., if they are in the DHS. 3. Knowledge of contraception methods (or if it were important exposure to family planning messages) may be an intermediate variable because it's impossible to use a method without knowledge that the method exists. The choice to divide into no, 1-5, and 5+ seems unrelated to practice, however. In practice, someone just needs to know 1 modern method in order to use it, and knowing 5 methods isn't necessarily better than knowing 4 methods or 3 methods, as long as they have access and can use one method. Also, some of these methods in the list aren't useful for childless people with future fertility intentions: female and male sterilization, lactational amenorrhea. Also, emergency contraception isn't a first line contraception, so maybe a different category. Consider reconceptualizing the variable to address the methods that would be most important for people of this age and life stage. If you think this variable is important, consider evaluating whether knowledge of contraceptive methods is a mediating variable using a mediation method. The medeff command in Stata by Dustin Tingley and Raymond Hicks will do one type of mediation analysis from Imai, Keele, and Tingley that is easy to interpret. 4. The study should describe practical implications of this study. You may need to do additional analyses to answer this question. These are some suggestions:a. Based on analysis of these data, what are the bad outcomes of not using modern contraception? That is, among the married and unmarried young women in this dataset who are not using modern contraception, can you find any outcomes that might be the result of not using modern contraception? Do you see evidence that they're leaving education earlier than they would have otherwise, having unplanned pregnancies, have bad marriages that they can't leave due to children, have STIs? b. Within these data, who are the success stories? Who are the people who would be expected not to use contraception but nonetheless are using modern contraception? Can we learn from them? Can these people point to what interventions could be done to improve contraception access for everyone? c. You mention Youth Information Corner in the conclusion without explaining what this is and why it's important. It should be mentioned earlier and described and explain how to improve it to help both married and unmarried young people. Based on this research, what should be done differently in order to improve access to contraception, knowledge of contraception, and acceptance of contraception? What populations and which ages could be targeted with which interventions? If you were going to write a grant to propose a program or intervention, what would you propose? If these interventions were done, what positive impacts would there be? d. It looks like exposure to family planning messages aren't associated with greater use --- does that mean that any message-based interventions aren't likely to be effective because they rely on exposure to family planning messages? e. Based on this study, what should be looked for in Myanmar's 2021 DHS that seems to be currently in the field? If you were going to add questions to the DHS in the future, what would you want to know? What study will you do using this 2021 DHS? Are there any policies that have happened between these two studies that might predict a change in the associations you have observed?f. Males are less aware of contraception options, and they are less likely to report use of certain methods such as injectable contraception, which may mean that they just didn't know that their female partner was getting them. Are the males taking enough responsibility here? How should interventions target males to involve them in contraception choices? What barriers need to be overcome to include males more and to improve their motivation to learn about contraception? Do you see evidence that any males are possibly preventing female partners from accessing contraception? Can you find any attitudes measured on DHS that explain which males are more involved in contraception choices? 5. Stepwise regression is not considered a rigorous method for finding important variables because it ends up just finding the p-values that are significant, which may differ across datasets. That is, if you repeated this analysis in the 2021 Myanmar DHS, you might find other variables are important. Using a cross-validation approach of choosing the variables based on analysis of another dataset (e.g., is there an earlier DHS?) and then testing the variables in this dataset is more rigorous. An alternative method is to identify the most important variables based on theory, add them in order of importance, and keep them in even if not significant if they aren't hurting the model. To the extent feasible, identify a method for variable choice other than stepwise regression. Andrew Gelman writes about stepwise regression in his blog here and the comments have a lot of resources: https://statmodeling.stat.columbia.edu/2014/06/02/hate-stepwise-regression/ Suggested revisions:1. If possible, Figure 1 would be nicer to show histogram of the number of methods, not the 3 broad categories. Even better, consider a dot plot (Cleveland's dot plot, seems to be graph dot in stata) to show the gap of male married vs female married knowledge of each method, and another dot plot showing the gap between male unmarried vs. female unmarried. The specific method information is really much more interesting than the number. It's also possibly more actionable.

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Reviewer #1: Title

This paper appears one of important papers about sexual and reproductive health among Myanmar youth. However, why use the word “further analysis”? Was there any similar paper about contraceptive methods/practices?

Introduction

This session highlighted the linkage between utilization of contraceptive methods and low maternal and neonatal deaths. In Myanmar, is there any study about the utilization of contraceptive methods among youth or general population? If no, it should specify in introduction session because it is one of knowledge gaps for this study.

Research aim

The research aim well reflects the purpose of this study. But, one thing, because it mentioned to meet the mandates of policies and program of Myanmar, what are the mandates, current situation, and gaps of policy implementation? It should mention in introduction session.

Methodology

The use of cross-sectional design is appropriate for this study. The sampling method is clear. However, is there any inclusion criteria or exclusion criteria for sample selection? Giving detail explanation will help the readers in understanding the research results.

Line 114-115: “Women's employment variable was recoded as "yes" if he or she currently had an earning job”. It makes a little confused why the man with an earning job is recorded as “yes” for women’s employment. Does it mean the husband/man has a job to be recorded as women’s employment, not wife/woman?

Statistical Method

The use of STATA software is appropriate for this study.

What motivates to use “age variables” into categorized group, rather than continuous variables? Is there any change if the age variable is applied as a continuous one in the regression analysis?

Results

The finding represents the statistical analysis performed by the authors.

Report mean age and standard deviation for each group of age.

Just a curiosity, why did the analysis not perform for never-married youth?

Discussion

This study well discussed about the findings by using comparative global studies and sound theoretical background.

Additionally, it should highlight some interesting facts such as male participants did not use male condoms (which is the main contraceptive method for men, and this is one important issue for program implementers.) and about 7 percent of study participants did not know any modern contraceptive method (it means about 93 percent of participants knew at least one contraceptive method. Is it the achievement of health education program?)

For limitation of study, is there any bias during interviews? For e.g., the informants selectively response the questions such as not telling the use of contraception due to cultural barriers especially for unmarried youth.

Conclusion

The study could be improved by clarifying the gaps between current program implementation and the findings of the study. The authors’ recommendations are appropriate, but it would be more effective if the study suggest the supportive role of society to create a sound environment in utilization of contraceptive methods. For e.g. The family planning program should expand its health education sessions to not only married couples but also all reproductive ages in the country. It is just optional.

Grammatical errors

Please review the manuscript for grammatical and spelling errors.

Recommendation

I would like to recommend acceptance of this paper after the authors have reviewed and addressed the above suggestions.

Reviewer #2: The study's purpose and analysis are terrific. The introduction is well-highlighted that it is crucial to determine social determinants of high teen birth rates, especially in developing countries.

Table 4 should state the statistical method used for the analysis to find more helpful for the audience.

Some interpretations should use " how many times higher or lower" instead of jargon (aOR) in results secession. Then, the author should state controlling other covariates while interpreting the multivariate logistic regression analysis.

Knowledge of the number of contraception methods " Known modern methods" showed a trend of dose-response relationship supporting a stronger causal relationship between knowledge of the number of contraception methods and utilization of contraception.

In discussion, the first few sentences are reiterated the above findings. Then, emphasizing the dose-response relationship will add a more powerful point to convince the conclusions of " The knowledge on modern contraceptive methods favored the utilization." The present study's findings agreed to similar findings that the authors referenced. (Reference no 18).

Strength and limitation: some of the final models in the male and ever-married population did not reach significant findings, probably due to a small sample size ( male = 1,423 and ever married = 1,424).

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PLoS One. 2021 Oct 6;16(10):e0258142. doi: 10.1371/journal.pone.0258142.r002

Author response to Decision Letter 0

22 Jul 2021

Responses to Academic Editor

Dear Dr. Janet E Rosenbaum

We appreciate your insightful comments and for giving valuable suggestions that improve our paper a lot.

Author's response – We followed your suggestion, and separate analyses were done for married females, unmarried females, married males, unmarried males. Please see in the results section (Lines 174-301).

Choose a health behavior model and use it to guide the study and choose important variables. Some important variables could be self-efficacy to use a method, perceived risk of pregnancy, not wanting pregnancy now, etc., if they are in the DHS.

Author's response – Thank you for providing this good article. We cited this article in our manuscript with reference number [20].

Since we are conducting secondary data analysis using DHS data, we don't have enough variables to measure the health belief model's constructs – perceived susceptibility, severity, barriers, benefit, efficacy, and cue to action.

However, we added two more variables that might influence utilization – sexual activity and desire for more children. Please see Lines 139-142.

3. Knowledge of contraception methods (or if it were important exposure to family planning messages) may be an intermediate variable because it's impossible to use a method without knowledge that the method exists. The choice to divide into no, 1-5, and 5+ seems unrelated to practice, however. In practice, someone just needs to know 1 modern method in order to use it, and knowing 5 methods isn't necessarily better than knowing 4 methods or 3 methods, as long as they have access and can use one method. Also, some of these methods in the list aren't useful for childless people with future fertility intentions: female and male sterilization, lactational amenorrhea. Also, emergency contraception isn't a first line contraception, so maybe a different category. Consider reconceptualizing the variable to address the methods that would be most important for people of this age and life stage.

If you think this variable is important, consider evaluating whether knowledge of contraceptive methods is a mediating variable using a mediation method. The medeff command in Stata by Dustin Tingley and Raymond Hicks will do one type of mediation analysis from Imai, Keele, and Tingley that is easy to interpret.

Author's response – According to your suggestion, we did not divide the knowledge into no, 1-5, and 5+. Instead, we used it as a linear score range 0-11. Please see Line 127-128, Table 5, and Table 6.

We follow the Myanmar Demographic and Health Survey annual report [10], in which all these 11 methods are considered modern contraceptive methods. https://mohs.gov.mm/cat/MDHS%20(2015-16) We assessed their knowledge for these contraceptive methods; however, for utilization, we interpret the availability and the most commonly used methods among youth.

We used the knowledge variable as one of the independent variables rather than a mediating variable.

4. The study should describe practical implications of this study. You may need to do additional analyses to answer this question. These are some suggestions:

a. Based on analysis of these data, what are the bad outcomes of not using modern contraception? That is, among the married and unmarried young women in this dataset who are not using modern contraception, can you find any outcomes that might be the result of not using modern contraception? Do you see evidence that they're leaving education earlier than they would have otherwise, having unplanned pregnancies, have bad marriages that they can't leave due to children, have STIs?

Author's response – Since we conduct secondary data analysis using MDHS data, some variables that need to answer your questions are not available in the data. Hence, we added these limitations to the discussion. Please see lines 411-416.

b. Within these data, who are the success stories? Who are the people who would be expected not to use contraception but nonetheless are using modern contraception? Can we learn from them? Can these people point to what interventions could be done to improve contraception access for everyone?

c. You mention Youth Information Corner in the conclusion without explaining what this is and why it's important. It should be mentioned earlier and described and explain how to improve it to help both married and unmarried young people. Based on this research, what should be done differently in order to improve access to contraception, knowledge of contraception, and acceptance of contraception? What populations and which ages could be targeted with which interventions? If you were going to write a grant to propose a program or intervention, what would you propose? If these interventions were done, what positive impacts would there be?

Author's response – We added a paragraph about Youth Information Corner. Please see lines 88-95.

For other questions, we gave these recommendations according to our findings.

• The reproductive health program should emphasize the adolescents and never-married youth population, especially in areas with low utilization, such as from the hilly and rural areas, to have equitable access to quality reproductive health services and health literacy.

• Moreover, revitalization of Youth Information Corner (YIC) and youth-friendly reproductive health services are needed to increase reproductive health knowledge and utilization to prevent unsafe sex, unintended pregnancies, and abortions which might help in reducing maternal and child mortality."

d. It looks like exposure to family planning messages aren't associated with greater use --- does that mean that any message-based interventions aren't likely to be effective because they rely on exposure to family planning messages?

Author's response – We explain this finding in lines 360-367.

e. Based on this study, what should be looked for in Myanmar's 2021 DHS that seems to be currently in the field? If you were going to add questions to the DHS in the future, what would you want to know? What study will you do using this 2021 DHS? Are there any policies that have happened between these two studies that might predict a change in the associations you have observed?

Author's response – Although we planned to conduct the second DHS study in 2020, the global COVID-19 pandemic interfered with the survey and we cannot start conducting this survey the second time. We would like to add some questions you pointed out, such as bad and success stories of utilization, males' role in contraceptive utilization.

Some of these questions could not get the detailed answers using the quantitative survey alone; hence, we gave research implication that "Further studies using the mixed method approach should be conducted to explore the barriers and challenges of contraceptive utilization and male involvement in choosing contraception among youth." Please see Lines 428-430.

f. Males are less aware of contraception options, and they are less likely to report use of certain methods such as injectable contraception, which may mean that they just didn't know that their female partner was getting them. Are the males taking enough responsibility here? How should interventions target males to involve them in contraception choices? What barriers need to be overcome to include males more and to improve their motivation to learn about contraception? Do you see evidence that any males are possibly preventing female partners from accessing contraception? Can you find any attitudes measured on DHS that explain which males are more involved in contraception choices?

Author's response – We found very low utilization of condoms among both never-married and ever-married youth. This finding pointed out that female youth took responsibility for contraception. We discuss this finding in lines 332-335.

5. Stepwise regression is not considered a rigorous method for finding important variables because it ends up just finding the p-values that are significant, which may differ across datasets. That is, if you repeated this analysis in the 2021 Myanmar DHS, you might find other variables are important. Using a cross-validation approach of choosing the variables based on analysis of another dataset (e.g., is there an earlier DHS?) and then testing the variables in this dataset is more rigorous. An alternative method is to identify the most important variables based on theory, add them in order of importance, and keep them in even if not significant if they aren't hurting the model. To the extent feasible, identify a method for variable choice other than stepwise regression. Andrew Gelman writes about stepwise regression in his blog here and the comments have a lot of resources:

https://statmodeling.stat.columbia.edu/2014/06/02/hate-stepwise-regression/

Author's response – Thank you for pointing out the weakness of the statistically driven model. Hence, we chose the variables based on the literature search in which these variables were associated with the utilization. Then, we reanalyzed the theoretical driven model by using the enter method not removing any variable (including all variables found in the literature associated with outcome and available in data). Please see Table 5 and Table 6.

Suggested revisions:

1. If possible, Figure 1 would be nicer to show histogram of the number of methods, not the 3 broad categories. Even better, consider a dot plot (Cleveland's dot plot, seems to be graph dot in stata) to show the gap of male married vs female married knowledge of each method, and another dot plot showing the gap between male unmarried vs. female unmarried. The specific method information is really much more interesting than the number. It's also possibly more actionable.

Author's response – We revised Figure 1 and described it by mirror bar chart using Excel. Please see Fig 1.tiff file.

2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.

Author's response – We added some sentence for the consent taking and data anonymity issue. Please see lines 169-170.

Responses to Reviewer 1

Dear Reviewer

Thank you very much for you appreciations and thorough comments. We followed your comments and revised the manuscript.

1. This paper appears one of important papers about sexual and reproductive health among Myanmar youth. However, why use the word "further analysis"? Was there any similar paper about contraceptive methods/practices?

Author's response – We remove the word "Further" in the title. Please see the title.

2. Introduction

Author's response – We add a paragraph for previous studies and knowledge gaps for this study. Please see lines 96-102.

3. Research aim

Author's response – We add a paragraph regarding the Five-Year Strategic Plan for Young People's Health (2016-2020). Please see Lines 79-87.

4. Methodology

Author's response – I added selection criteria of the DHS survey in "Materials and Methods" section. Please see lines 110-114.

5. Line 114-115: "Women's employment variable was recoded as "yes" if he or she currently had an earning job". It makes a little confused why the man with an earning job is recorded as "yes" for women's employment. Does it mean the husband/man has a job to be recorded as women's employment, not wife/woman?

Author's response – We revised the sentence like that "The employment variable was recoded as "yes" if the respondent had an earning job within 12 months before the survey or "no" otherwise." Please see the line 135-136.

6. Statistical Method

The use of STATA software is appropriate for this study.

What motivates to use "age variables" into categorized group, rather than continuous variables? Is there any change if the age variable is applied as a continuous one in the regression analysis?

Author's response –Although we used age as a continuous variable, the findings were not changed in direction and its significant effect. All DHS annual reports categorized age into 5 years intervals. We follow this rule to be easier to compare with other countries' studies and reports. Hence, we categorized age into 15-19 and 20-24. Please check the reference [10].

7. Results

The finding represents the statistical analysis performed by the authors.

Report mean age and standard deviation for each group of age.

Just a curiosity, why did the analysis not perform for never-married youth?

Author's response – We reported mean age and standard deviation in Table 1 (Line 188). Now we added the findings of never-married youth in Table 6 (Line 300).

8. Discussion

This study well discussed about the findings by using comparative global studies and sound theoretical background.

Author's response – We added some sentences regarding male condoms utilization and responsibility regarding contraception among youth. Please see lines 332-335.

We mention the possibility of underestimation of utilization due to cultural barriers among unmarried youth in limitations. Please see lines 408-410.

9. Conclusion

The study could be improved by clarifying the gaps between current program implementation and the findings of the study. The authors' recommendations are appropriate, but it would be more effective if the study suggest the supportive role of society to create a sound environment in utilization of contraceptive methods. For e.g. The family planning program should expand its health education sessions to not only married couples but also all reproductive ages in the country. It is just optional.

Author's response – We would like to give some suggestions in conclusion as follow:

"The reproductive health program should emphasize the adolescents and never-married youth population, especially in areas with low utilization, such as from the hilly and rural areas, to have equitable access to quality reproductive health services and health literacy. Moreover, revitalization of Youth Information Corner (YIC) and youth-friendly reproductive health services are needed to increase reproductive health knowledge and utilization to prevent unsafe sex, unintended pregnancies, and abortions which might help in reducing maternal and child mortality."

Please see lines 426-433.

10. Grammatical errors

Please review the manuscript for grammatical and spelling errors.

Author's response –The manuscript was proofread to check grammatical and spelling errors.

11. Recommendation

I would like to recommend acceptance of this paper after the authors have reviewed and addressed the above suggestions.

Author's response – Thank you very much for your kind considerations.

Responses to Reviewer 2

Dear Reviewer

Thank you very much for you appreciations and thorough comments. We followed your comments and revised the manuscript.

1. The study's purpose and analysis are terrific. The introduction is well-highlighted that it is crucial to determine social determinants of high teen birth rates, especially in developing countries.

Table 4 should state the statistical method used for the analysis to find more helpful for the audience.

Author's response – We added the statistical method "Chi-square test for independence" in the Methods section and footnote of Table 4. Please see lines 152-153 and lines 245-246.

We remove the jargon in the interpretation. Please see lines 247-266 and line 272-299.

We add the phrase "adjusting the covariates" to interpret the multivariable binary logistic regression analysis. Please see lines 249 and line 273.

2. Knowledge of the number of contraception methods "Known modern methods" showed a trend of dose-response relationship supporting a stronger causal relationship between knowledge of the number of contraception methods and utilization of contraception.

Author's response – We added some sentences about the dose-response relationship of knowledge of modern contraceptive methods in the discussion. Please see lines 373-378.

3. In discussion, the first few sentences are reiterated the above findings. Then, emphasizing the dose-response relationship will add a more powerful point to convince the conclusions of "The knowledge on modern contraceptive methods favored the utilization." The present study's findings agreed to similar findings that the authors referenced. (Reference no 18).

Author's response – We remove the reiterated findings in the discussion.

4. Strength and limitation: some of the final models in the male and ever-married population did not reach significant findings, probably due to a small sample size ( male = 1,423 and ever married = 1,424).

Author's response – Thanks for giving a possible explanation for our findings.

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file.^{(53.1KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0258142.r003

Decision Letter 1

Janet E Rosenbaum

3 Sep 2021

PONE-D-21-13352R1

Utilization of modern contraceptive methods and its determinants among youth in Myanmar: Analysis of Myanmar Demographic and Health Survey (2015-2016)

PLOS ONE

Dear Dr. Mya,

Please submit your revised manuscript by Oct 18 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Janet E Rosenbaum, Ph.D.

Academic Editor

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

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Reviewer #1: The authors well responded to all comments of previous review. Thank you for well addressing them. However, after this current review, some minor comments came out to be addressed by the authors. Please find the following:

1. Line 127-128 Why was “the number of modern contraceptive methods known” not categorized? I think it was because reviewers suggested revising the category of this variable in the first review. In Table 5 and Table 6 of the revised manuscript, the value of this variable did not describe any reference category. If it intended to use continuous variable, the result of logistic regression on this continuous variable should be completely described in Table 5 and Table 6. On the other hand, if it used binary variable, the variable should be categorized into at least 2 categories. For example, “0” for nothing known, and “1-11” for knowing one and more methods or “no”/ “yes” category.

2. In Line 338, it described “most knew 4.5 to 8.8 contraceptive methods”. Numerically, it is true to describe the real value. But logically, the method should be counted in compete number. 4.5 or 8.8 Methods looks a little unrealistic. One method cannot be divided into 0.5 or 0.8 method. This is just optional.

3. Line 373 described dose-response relationship between knowledge and utilization. However, the manuscript did not describe the statistical values of this relationship in the result session. May be I misunderstood Table 6. My suggestion is to use a figure or illustration to describe “this dose-response relationship” for more understanding by readers.

4. Line 392-393 argued that youth from rich households utilized more contraceptives than ones from poor household. It looks contradictory to the finding. In Line 287, it stated that “Female youth from rich households were 32% less likely to use modern contraception than poor households”. Please review it and kindly keep consistency of manuscript.

That’s all from my side and I would like to recommend acceptance of this manuscript after the authors have addressed the minor suggestions.

Reviewer #2: (No Response)

**********

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Reviewer #2: No

PLoS One. 2021 Oct 6;16(10):e0258142. doi: 10.1371/journal.pone.0258142.r004

Author response to Decision Letter 1

6 Sep 2021

Responses to Reviewer 1

Dear Reviewer

Thank you very much for pointing out some mistakes of us. I revised according to your comments.

Author's response – We received the comments from the Academic editor not to categorize the number of modern contraceptive methods known; hence, we revised accordingly and treated it as a continuous variable. To clear the reader, we added a sentence at Line 128-129 "we treated this variable as a continuous variable."

Since we treated this variable as a continuous independent variable, we don't need a reference category for binary logistic regression analysis for the dependent variable (contraceptive utilization) in Table 5 and Table 6. We interpreted the results like how much odds of contraceptive utilization were increased or decreased as one more method knew.

Author's response – We agree with your comments since the number of known contraceptive methods was a discrete numerical variable. However, this finding was not our study's finding. We used the finding of reference number [32] to discuss knowledge of modern contraceptive methods.

Author's response – We performed a chi-square test for trend to describe this dose-response relationship and the results were described using Fig 3. Please see Fig 3 and the description of this figure in Lines 227-230.

Author's response – Thank you so much for pointing out this gross mistake. We revised this finding appropriately. Please see Line 399.

Other minor corrections by Author

1. In line 184 of the unmarked version, we replaced the words "three fourth" with "three-fourths".

2. In lines 260-261 of the unmarked version, we replaced the sentence "Youth from the hilly zone were 70% fewer odds to use modern contraception than those from the delta zone" with "Youth from the hilly zone had 70% fewer odds of using modern contraception than those from the delta zone".

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PLoS One. doi: 10.1371/journal.pone.0258142.r005

Decision Letter 2

Janet E Rosenbaum

20 Sep 2021

Utilization of modern contraceptive methods and its determinants among youth in Myanmar: Analysis of Myanmar Demographic and Health Survey (2015-2016)

PONE-D-21-13352R2

Dear Dr. Mya,

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

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

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Janet E Rosenbaum, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

**********

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

Reviewer #1: Yes

**********

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

Reviewer #1: Yes

**********

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

Reviewer #1: Yes

**********

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

Reviewer #1: Yes

**********

6. Review Comments to the Author

Reviewer #1: Dear Authors,

Thanks for addressing all the comments and I really appreciate it.

If you don't mind, I would like to provide this minor suggestion.

Line 401-403 Please review those lines and kindly adjust the meaning of sentence to be consistent with the revision (wealthy youth utilize less modern contraceptives than poor youth). Or, alternatively, it will not be a problem if those lines are deleted.

This is just optional and hope it will be helpful to you.

Thank you.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

PLoS One. doi: 10.1371/journal.pone.0258142.r006

Acceptance letter

Janet E Rosenbaum

24 Sep 2021

PONE-D-21-13352R2

Utilization of modern contraceptive methods and its determinants among youth in Myanmar: Analysis of Myanmar Demographic and Health Survey (2015-2016)

Dear Dr. Mya:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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

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

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Janet E Rosenbaum

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Attachment

Submitted filename: Response to Reviewers.docx

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Data Availability Statement

The Myanmar Demographic and Health Survey data can be downloaded from this URL - https://dhsprogram.com/data/available-datasets.cfm.

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PERMALINK

Utilization of modern contraceptive methods and its determinants among youth in Myanmar: Analysis of Myanmar Demographic and Health Survey (2015-2016)

Ciin Ngaih Lun

Thida Aung

Kyaw Swa Mya

Roles

Abstract

Introduction

Materials and methods

Dependent variable

Independent variables

Statistical analysis

Ethical consideration

Results

Table 1. The individual and household characteristics of youth in Myanmar.

Fig 1. Types of modern contraceptive methods known by youth in Myanmar.

Table 2. Number of modern contraceptive methods known by youth in Myanmar.

Table 3. Types of modern contraceptive methods used by youth in Myanmar.

Fig 2. Prevalence of modern contraceptive utilization among youth in Myanmar.

Fig 3. The modern contraceptive prevalence rate by the number of known methods among youth in Myanmar.

Table 4. The association between modern contraceptive methods utilization by background characteristics among youth in Myanmar (Bivariate analysis).

Table 5. Multivariable binary logistic regression analysis of modern contraceptive methods utilization among never-married male, ever-married male and ever-married female youth in Myanmar.

Table 6. Multivariable binary logistic regression analysis of modern contraceptive methods utilization among male youth, female youth, ever-married youth, and never-married youth in Myanmar.

Discussion

Strengths and limitations of the study

Conclusion

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Janet E Rosenbaum

Roles

Author response to Decision Letter 0

Decision Letter 1

Janet E Rosenbaum

Roles

Author response to Decision Letter 1

Decision Letter 2

Janet E Rosenbaum

Roles

Acceptance letter

Janet E Rosenbaum

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

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