Title: Barriers to using postpartum family planning among women in Zanzibar, Tanzania
Version: 1 Date: 19 Dec 2022
Reviewer:  Batula Abdi
Reviewer's report:
This is an important area which is under study, particularly the uptake of post-partum
family planning among Muslim communities. This study can inform culturally appropriate
programming with some revisions.
See specific comments below;
Background
1. It is essential to emphasize the importance of FP and indicate the contribution of FP in the
reduction of maternal and child mortality by 30% and 10%, respectively - there are a number
of studies that have shown this please include.
2. It is important to note the inequalities in terms of contraceptive uptake Zanzibar has places
that have a single-digit CPR in Pemba- showing the regional variation is vital so that inequalities
in FP uptake in not masked by national averages.
Methodology
Although the methodology is described, there is a need to describe the process more;
1. Since the interviews were conducted in the maternity or the postnatal ward, the authors need
to state how privacy (especially audio) was assured.
2. The ethical clearance needs to be mentioned in the methodology section as well apart from
being mentioned in the declarations.
3. The authors need to describe how the quality assurance during data collection and analysis
was done, for example, comparing the merging themes and subthemes and how discrepancies
if any, were addressed.
4. In the methods sections, it is indicated that the women who participated in the interviews were
a total of 24; please indicate how many women per FDG and if age variation and parity were
considered when constituting the groups
Results section
1. One of the themes the authors explain in the results is- Insufficient family planning services.
Family planning services encompass a number of issues that include the availability of Family
planning community, trained health care providers that have the appreciate skill mix etc. Reading
through the results, the core issue seems to be the quality of care which related to FP counselling
and the perceived knowledge of healthcare providers. It is very important to be specific with the
framing of the results. The quotes from women show that they feel the heal care providers do
not have the time required knowledge.
2. There is a mention of trusting in God, it will be nice to explore further the data on the nuances
to this; religious misinterpretation has been a key barrier- you may want to explore further under
the theme of – Belief in traditional medicine for FP where Quran is mentioned, or religion can
fit in any of the other themes such need to involve husband
Discussion
The discussion section needs to be further strengthened since the lines are not numbered and
will refer to paragraph numbers and pages;
1. Second paragraph on the discussion page 13, the para that starts with-- This could be a
consequence of insufficient family planning services that fail to reach out with accurate and
understandable information. As mentioned in the results, it is important to nail this to the core
issue, which is quality of care and provider skills. It is also good to contextualise this to the
context of Zanzibar- like any other developing country, human resources for health is a big
problem in Zanzibar - there is a need to expand the issue of quality of care in the discussion
relating to provider skills, and shortage of essential staff.  The same paragraph leads to another
issue of sexuality education; note the correct wording is Sexuality education which is broader
terminology but not sexual education as indicated. This para has two issues lamped together, the
knowledge on contraception which is supposed to be provided by skilled health providers and
the issue on sexuality education- both are very important- you may want to have a paragraph
to each relating to existing evidence.
2. Third para page14, the sentence starts with - the most important clinically relevant finding in
this study was that male involvement and education was desired from the women’s perspective-
the term clinical finding is not correct, male involvement is not a clinical issue but rather a social
strategy to enhance uptake of sexual and reproductive services. Consider rewording this.
Conclusion
1. The conclusion section speaks well to the results; the specific quality issues such as
counselling is covered. It is essential to highlight the need for sexuality education and investment
in woman’s education, in general, to enhance gender equality and woman’s agency to make
decisions on their health.