Reviewer ’s report  
 
Title: Can community health workers play a greater  role in increasing access to medical abortion 
services? a qualitative study  
 
Version: 0 Date: 30 Sep 2016  
 
Reviewer: Kelly Blanchard  
 
Reviewer's report:  
 
Expanding access to safe abortion information and services is critical to promote the health and 
rights of women in India.  Building on the existing CHW structure/interventions is a promising 
approach, as shown by other research cited by the authors.  This study investigating the opinions 
and experiences of women and CHWs using qualitative approaches provides important 
information to develop interventions that both take advantage of  the opportunities a greater role 
for CHWs presents, and also addresses the concerns of women and CHWs.  The findings 
presented here are an important addition to the literature.  
In a number of places throughout the paper, it would be helpful to readers to  have some more 
information to better understand the methods as well as the findings and recommendations.  
In the abstract and in the discussion, the authors recommend additional intervention research to 
shed light on the effectiveness of CHWs in facilitating access to safe abortion.  It would be 
useful to provide some more detail about the type of research tha t would be helpful based on this 
qualitative research as well as the clinical research cited in the paper.  
It was not clear from the paper whether the authors believed provision of medication abortion 
drugs might be considered as a possible role for CHWs —it would be useful to hear whether their 
experience suggests this would be worth exploring/testing.  In the Background lines 73 -81 it 
would be useful to provide more detailed findings from the main study on eligibility for medical 
abortion —i.e. what does m oderate to high agreement between CHWs and clinicians mean and 
does that data support a more active role for CHWs in provision of medication abortion drugs?  
In the Methods section the authors say the study "covered" women seeking care from 5 health 
centre s.  It might be clearer to say women who were participating in the main study were 
purposively sampled for the qualitative study.  In the first paragraph of the Methods section it 
says women seeking care at 5 centres were included but in the third paragrap h it says the sample 
was selected from women presenting at three study clinics —please clarify, and please provide 
additional information about the types/locations of the clinics (urban, rural, level, etc.).  
Were interviews with women and CHWs recorded?  T he authors say the team prepared verbatim 
transcripts but it is not clear if that is from notes or from audio recordings.  
Table 1 could probably be formatted to take up less space.  The information is useful even for 
this small sample.  Were the women rec ruited throughout the main study?  Were there 
targets/goals by time period?  
In the discussion of the CHW results, it was sometimes challenging to follow when the authors 
were discussing ASHAs, when they were discussing NGO CHWs, and when they were 
combini ng the results.  Was an aim of the analysis to see if there were differences?  Is it true that 
when the results describe CHWs that the reader can interpret that as there not being significant 
difference/different themes by CHW type?  If yes, it might be he lpful to the reader to know that 
up front.  
In the description of problems encountered by rural CHWs, was this true of both groups?  The 
second quote in this section does not have a descriptor for the source.  Did CHWs in urban areas 
not report experiences  of women accessing tablets outside of a health facility?  In the section 
below about CHWs contacting women after abortion it seemed that perhaps the practice of 
seeking tablets from a chemist and concerns/reasons to choose not to attend a formal facility 
were more common.  It would be very useful to clarify this, and in the discussion perhaps 
address whether CHWs have a role to play in expanding access to care in a confidential manner 
that overcomes some of the concerns about visiting a facility.  From the  results presented, it 
sounds like CHWs doing follow -up is certainly possible and might address financial, time and 
confidentiality constraints.  
Lines 311 -313 are somewhat concerning in that it sounds like the CHWs and the physicians 
might not be offering  women a free choice of contraceptive method, although this may be a 
language issue.  Are CHWs in a position to help ensure women have full information about a 
range of methods without pressure to use any specific method?  Do CHWs work under targets 
for co ntraceptive uptake that need to be made explicit?  In line 472 the authors say ASHAs 
"actively promote" sterilization" but the comments suggest some ASHAs might be pressuring 
women to sterilize, but in some cases women report ASHAs might be a better source  of support 
instead of a facility where they are likely to be pressured.  Are there efforts to address this issue 
re family planning?  It sounds like this is a broader issue than CHW roles in abortion care.  
In the findings from women, the authors describe  their experience with and opinions about 
services provided by ASHAs.  Were they not asked specifically about CHWs affiliated with 
NGOs or did women who participated not have experience with them?  
The findings about fear of pressure from AHSA's when seeki ng abortion advice (lines 345 -362) 
also suggested challenges with accessing family planning services that do not pressure women to 
use a specific method —does this issue deserve more attention in the discussion?  
Women were specifically asked about consulti ng ASHA's for diagnosis/information about 
unintended pregnancy and where to access abortion services —were they asked about CHW 
provision of abortion medications?  Is that something useful to consider?  Is there a specific 
reason that CHW provision of medic ation abortion was not considered in the main study or the 
qualitative study?  
In the first paragraph of the Discussion the authors said women "reported lesser contact with 
CHWs when faced with an unwanted pregnancy…"  It might be useful to discuss here wh ether 
that is because of their concerns, or because the CHWs were not specifically trained and 
perceived as a source of information about abortion.  Because women have different feelings 
about CHW involvement, would the authors feel comfortable saying/does  the data support the 
conclusion that a range of entry points into abortion services is important?  
In the Discussion line 492, did this finding not also apply to NGO CHWs?  Again it would be 
useful to clarify where in the paper the authors are referring t o one or the other group and why 
some sections appear to address only ASHAs when NGO CHWs were also interviewed.  
The point about the study only addressing the opinions and experiences of women who reached a 
safe abortion service is a very important one.  Would the authors recommend further research 
address this issue?  It would also be useful to clarify the next sentence in that paragraph. The 
authors say they could not explore women's views of NGO CHWS —was this because women in 
this sample did not have ex perience with those CHWs?  Please explain.  
In the Conclusion, the point about the need to provide balanced counseling is a good one, but 
perhaps the recommendation goes beyond what would make a program to expand access to safe 
abortion services successful , but is also an issue that should receive more attention in ongoing 
ASHA and other CHW training for contraception provision?  Should there be a recommendation 
here about monitoring quality of ASHA/health center contraceptive counseling and provision?  
Finally, would the authors recommend pilot programs also address CHW provision of 
medication abortion drugs?  
Thank you for the opportunity to review this manuscript.  
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary contro ls? 
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality o f written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
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