Reviewer ’s report  
 
Title: ‘Leaving no one behind ’: A literature review on the provi sion of sexual and reproductive 
health care to nomadic populations  
 
Version: 0 Date: 11 May 2019  
 
Reviewer: Linnea Zimmerman  
 
Reviewer's report:  
Review notes  
Overall, this publication highlights the lack of research and pro grammatic focus of reproductive 
and maternal health of a neglected population, nomads.  It synthesizes the sparse literature that is 
available by identifying internal and external barriers to receiving care and identifies potential 
solutions.  While this i s an important subject and it is worthwhile to highlight this population and 
synthesize the findings that are available, more work is needed in the introduction and discussion 
section before this manuscript is ready for publication.  Specifically, the intr oduction is 
insufficient in its description of what is known generally about nomadic populations and the 
discussion reads as repetitive of the results section.  Additional external research of successful 
programs that are not specific to nomadic population s but which the authors suggest could be 
adapted would strengthen the conclusions.  I encourage the authors to revisit these sections and 
resubmit the manuscript as this is a relevant and important topic.  
 
Major comments  
In general, the introduction is q uite short and could be strengthened. For example, page 2, line 15 
and 27 - Are there numbers that can be cited here? Estimates on the numbers of nomads 
worldwide?  Although use of health services may be low, if overall numbers are also quite low, 
then imp rovement in this population may not lead to large changes worldwide.  It is critical to 
supplement with more information to support this claim.  More information on nomadic 
populations overall, including any estimates of RH outcomes such as maternal health  and FP use 
would strengthen the argument why this review is necessary.   
 
Page 8, section b - I think this section needs more detail. What are the components of the mobile 
health care mentioned that made them successful?  
 
Page 8, line 47 - HEWs in Ethiopi a are trained in some aspects of delivery but are not 
encouraged to be the sole attendant in home deliveries. https://cdn2.sph.harvard.edu/wp -
content/uploads/sites/32/2014/09/HSPH -Ethiopia4.pdf.  There is a fair amount of literature on 
the HEW program, inc luding strengths and weaknesses.  Reviewing some of this literature, even 
for non -nomadic populations, and identifying what components are successful and what 
components are not would strengthen the conclusions.  
   
Page 10, section g - Though I do not disa gree that improving education is critical, it is unclear 
how this could be done with nomadic populations, given their migratory nature. Do any of the 
papers address this?  Are there successful programs where this has been done?  If so, should be 
included i n the discussion  
 
Page 10, line 51 - Do you mean HEWs or TBAs?  These are not the same but in the context of 
this sentence, it is not clear to which you are referring. WHO guidance is that TBAs should not 
be treated as skilled birth attendants, but serve a s liasons to the formal health system, given the 
lack of evidence that trained TBAs have better birth outcomes.  This needs to be addressed in the 
discussion.  https://extranet.who.int/rhl/topics/improving -health -system -performance/who -
recommendation -partn ership -traditional -birth -attendants -tbas  If the authors want to suggest that 
those recommendations do not work for this population, that is fine, but need to cite additional 
evidence and arguments on how to effectively use TBAs.  
 
Overall, I found the di scussion to be limited. It seemed primarily to summarize the results again, 
rather than build on them.  Are there examples of successful strategies to improve RH health 
from other populations that can be adapted?  I understand that the review was limited t o a 
specific population, but the recommendations are often too non -specific to be helpful.  Increase 
government investment, improve education?  Agreed, but how can this be done?  More detail of 
why some of the strategies worked while others do not would  b e useful. The review mentioned 
improving engagement with men; are there successful strategies of this done elsewhere that the 
authors could suggest as models for nomadic populations?  What about community involvement 
- many programs have worked on improvin g community engagement.  Are there lessons learned 
that could be adapted for pastoralists?  A recommendation is a need for more research but are 
there specific priorities?  Page 11, line 46 hints that there are. How might researchers adapt 
research methodo logies to better capture nomadic populations?  
 
The call for more research as the primary conclusion seems somewhat misaligned with the 
results and discussion. I agree it's necessary as the literature is demonstrably sparse, but the 
authors did not discuss any of the limitations in the research conducted or remaining questions 
that the papers highlighted before making this suggestion.  The authors state that the purpose of 
the paper was not to review the quality of the previous studies, and I understand that , but at the 
same time, no discussion of the limitations of what is currently known undermines the argument 
that more research is needed. There needs to be more integration in the discussion about why the 
results that are suggested are incomplete without m ore research.   
 
Minor comments -  
Generally the paper is well written, but there are multiple grammatical errors.  I originally 
identified them, but deleted and defer to the publication editors.  A review by a copy editor 
would be beneficial. Additionally, there were several statements throughout the paper that would 
have benefited from citations.  
 
Page 2, line 10 - would avoid using "we" for groups beyond the author team (such as in 
statements suc h as "we focus on populations" (line 10)).  
 
Page2, Line 21 - needs citation  
 
Page 2, Line 24 - needs citation  
 
Page 2, Line 45 - Suggest "barriers to accessing reproductive"  
 
Page 3, Line 42 - needs citation  
 
Page 3, Line 46 - may be discretion of journal,  but generally data is plural.  Data were, not data 
was 
 
Page 3, unclear where the footnote comes from.  Make a citation  
 
Page 5 line 49 - citation  
 
Page 6, line 46 - suggest citation  
 
Page 6, line 50 - remove countless. Replace with less dramatic verbiage .  
 
Page 6, line 60 - suggest citation  
 
Page 7, line 35 - inconsistent tense.  Switched from past to present  
 
Page 8, section a - Is the recommendation of universal health coverage from a paper(s)? If so, it 
should be cited. If not, it should be put into t he discussion.  
 
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.  
 
No 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy 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:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
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