Reviewer’s report
Title: Investigating the quality of family planning counselling as part of routine antenatal care and
its effect on intended postpartum contraceptive method choice among women in Nepal
Version: 0 Date: 17 Nov 2019
Reviewer: Karen Hardee
Reviewer's report:
This manuscript covers an important topic - the quality of family planning counseling regarding PPFP,
and women's perceptions of that counseling.   The title of the manuscript is misleading however in that
it implies that the counseling each women receives is linked to the method she selected (if any)
postpartum.  The paper doesn't actually do that.  Why not add "intended" to the title - "intended
postpartum contraceptive method choice among women in Nepal"?
It would be useful to add some information about the broader evaluation within which the data for this
manuscript are embedded.  Readers are referred to Pradhan et al. (2019), "which demonstrated a
relatively small effect of the intervention on PPIUD counseling rates."  I found Pradhan et al. (2019),
which says: 
"Our analysis shows that the intervention increased PPIUD counseling by 25 percentage points. It also
increased PPIUD uptake by four percentage points. If all women were counseled by the program,
PPIUD uptake would have increased by 17 percentage points."
It would be useful to add this finding to the current manuscript so that readers don't have to go to that
other article to understand the context for this study.  Also, is a 25 percentage point increase in PPIUD
counseling really a relatively small effect?  Perhaps the authors could couch that finding as asking why
the intervention didn't result in an even higher effect on PPIUD counseling.  
As an aside on the Pradhan et al. (2019) paper - did the authors also measure whether women chose
some method of contraception PP - isn't the point of full, free and informed choice that women choose
the method that is best for them.  Even if they were counseled on the PPIUD it is perfectly okay for
women to choose another method.  And even if they were counseled and chose no method, that might
also be the right decision for some women.  Was there any measure of women's satisfaction with their
choice PP?  The authors make the point in the discussion that interventions that focus on one method
run the risk of that method being the one promoted by providers (which can also come from promotion
by programs or donors).  
Still, understanding women's experience with counseling in the context of the intervention is useful,
even if the findings from this study are sobering.   Use of the Bruce/Jain QOC framework as an
organizing frame for the results is good, although I suggest that the authors look at the updated FP
QOC framework that revises the original framework to incorporate definitions of quality in rights-
based  frameworks.   See  Jain  and  Hardee,  2018:
https://onlinelibrary.wiley.com/doi/full/10.1111/sifp.12052.  The reason the revised framework would
be useful is that it divides the components of quality into structure and process - which relates to the
finding in this manuscript that there are structural barriers to provision of quality counseling on PPFP.   
Other comments: 
The paragraph in lines 95 to 110 is a bit of a jumble.  The previous paragraph is about PPFP and this
paragraph starts with the barriers to accessing FP generally, low use of IUDs and barriers to PPFP.  The
information on general barriers could be deleted, or shortened.  The paragraph could start with the
barriers to PPFP, with some additional general barriers relevant to PPFP noted.  I would take the part
about the IUD out of this paragraph and add something in the next paragraph about why the FIGO
study focused on the IUD.   
The sample for this study seems highly urban and educated.  It would be useful to have a comparison to
the last DHS on % urban and the education distribution, and maybe the occupation - just to give a sense
of how this sample of women compare.  I realize that the authors do not claim that this sample is
representative, but it would help readers situate this sample of women.
Would it be possible to include in table 2 of the method the women said they intended to use PP - if that
was asked of women in the interviews.  It would be interesting to see how many women were still
undecided - or if the women who were more satisfied with their counseling had made a choice.    
It seemed from the findings that the women in Group 2 hospitals tended to receive better counseling -
Line 497 said that "this may be due to the intervention's posting of a designated counselor at the time of
interviews."  This sentence is not clear - "at the time of the interviews"?  You mean for the interviews
for this study - or that the intervention was adapted when it came to Group 2 hospitals to add a
designated counselor?  Please clarify. 
It also seems from the findings that higher educated women were treated better than women with no or
little education (provider-client interaction).  Could the authors say more about this?  
Line 506 - including men/husbands is a good idea.  What about also suggesting that the women take the
brochures home for their husbands to see.  It is likely that husbands have higher literacy rates than their
wives and if they are instrumental in decision-making on contraceptive use, that might be easier than
getting them to come to the clinics.  Perhaps the brochure could be given at the first ANC visit, with
more counseling provided at subsequent ANC visits after the woman has discussed the brochure with
her husband.  
In the conclusion, the authors note that "These qualitative findings have implications for improving
family planning services in Nepal, particularly as part of ANC and PNC services in hospital settings."
The suggestions seem reasonable - but how feasible will it be/how much might it cost to make
"improvements  in  the  health  system  infrastructure  (health  provider  availability,  knowledge  and
behavior with clients) to allow for ample time and resources during ANC visits" in order to (i) counsel
on family planning methods including the pros and cons of each choice, (ii) strengthen use of  PPFP
IEC  video  playing  in  ANC  waiting  rooms  to  utilize  the  limited  time  women  may have  to  gain
information about family planning, and (iii) involve male partners in the family planning counseling
sessions and discussions." Presumably, the intervention funded through FIGO and the donor was well-
resourced.  What would it take for Nepal to make the improvements the authors are proposing?  
Finally, the authors note in the limitations that the findings in the study are from the perspective of
what women remembered about the counseling they received.  That perspective is really important -
since what women remember about what they were told and how they perceive they were treated
reflect their experience.  Still, it would have been useful to talk with some providers to understand the
constraints  they  face  in  providing  counseling.   If  the  providers  were  trained  through  the  FIGO
intervention and still did not provide quality counseling, it is important to understand why in order to
make improvements.  
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
Unable to assess
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 of written English
Please indicate the quality of language in the manuscript:
Acceptable
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